HomeMy WebLinkAboutPR 19816: TO AMEND THE STATE HEALTH SERVICES PRIMARY HEALTH CARE PROGRAM City of 14)
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Texas
DATE: June 13, 2017
To: Brian McDougal, City Manager
From: Judith A. Smith, RN, BSN
RE: Approval To Amend The Contract Between the Department of State Health Services
Primary Health Care Program and the City of Port Arthur
Nature of the Request: This is a request to amend the contract ID # 2016-048585 with Texas
Department of State Health Services to increase the total amount of the contract to $280,000, of
which $140,000 is allocated toward the contract period of September 1, 2017 through August 31,
2019. This Primary Health Care contract provides preventive health services including
immunizations, diagnosis and treatment of acute illnesses, family planning, health education, and
diagnostic tests including lab and x-ray for eligible participants at or below 150% of the current
federal poverty guidelines.
Analysis, Considerations: The contract period starts 09/01/2017 and ends 08/31/2019 and
provides for salaries and fringe benefits for one full-time eligibility/billing clerk.
Recommendations: It is recommended that the City Council approve P.R. No. 19816 for the FY
2018-19 contract between the Department of State Health Services Primary Health Care Program
and the City of Port Arthur program to provide primary and preventive health care services.
Budget Considerations: The total budget is $280,000 to cover the cost of salaries, fringe
benefits, supplies, contractual and travel for a two year period.
"REMEMBER WE ARE HERE TO SERVE THE CITIZENS OF PORT ARTHUR"
P.O.BOX 1089•PORT ARTHUR,TX 77641-1089.409/983-8101•FAX 409/982-6743
P. R. NO. 19816
06/08/2017-js
RESOLUTION NO.
A RESOLUTION APPROVING THE AMENDMENT OF THE FY
2016 CONTRACT BETWEEN THE CITY OF PORT ARTHUR
AND THE DEPARTMENT OF STATE HEALTH SERVICES
PRIMARY HEALTH CARE PROGRAM, INCREASING THE
AMOUNT TO $280,000, OF WHICH $140,000 IS ALLOCATED
TOWARD THE CONTRACT PERIOD SEPTEMBER 1, 2017
THROUGH AUGUST 31,2019.
WHEREAS, the FY 2016 Primary Health Care contract was approved by council
on September 15, 2015, Resolution No. 15-334 for funding for FY 2016; and,
WHEREAS, this program provide preventive health services including
immunizations, diagnosis and treatment of acute illnesses, family planning, health
education, and diagnostic tests including lab and x-rays for eligible participants at or
below 150% of the current federal poverty guidelines: and,
WHEREAS, this is an amendment to the FY 2016 contract increasing the total
contract not to exceed $280,000, of which $140,000 is allocated toward the contract
period of September 1, 2017 through August 31, 2019.
NOW THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF
THE CITY OF PORT ARTHUR:
Section 1. That, the facts and opinions in the preamble are true and correct.
Section 2. That, the City Council of the City of Port Arthur hereby approves
the contract amendment between the City of Port Arthur and the Department of State
Health Services.
P. R. NO. 19816
Paget—js
Section 3. That, the City Council deems it is in the best interest of the City to
approve and authorize the City Manager to execute the contract amendment between the
Department of State Health Services and the City of Port Arthur for Primary Health Care
Services, as delineated in Exhibit"A."
Section 4. That, a copy of the caption of this Resolution be spread upon the
Minutes of the City Council.
READ,ADOPTED,AND APPROVED,this day of June, 2017
A.D., at a Regular Meeting of the City Council of the City of Port Arthur, Texas by the
following Vote:
AYES: Mayor:
Councilmembers:
NOES:
Mayor
ATTEST:
Sherri Bellard, City Secretary
P. R. NO. 19816
Page 3—js
APPROVED AS TO FORM:
\cd. d -
Val Tizeno, Ci ttorney
APPROVED FOR ADMINISTRATION:
uthhitib
Brian McDougal J ith Smith, RN, BSN
City Manager Director of Health Services
Attachment — FY 2018 & FY2019 Renewal
Signature Document
SIGNATURE DOCUMENT FOR
HEALTH AND HUMAN SERVICES COMMISSION
CONTRACT No.2016-048585-002
UNDER THE
PRIMARY HEALTH CARE GRANT PROGRAM
I. PURPOSE
The Health and Human Services Commission ("System Agency") and City of Port
Arthur("Grantee")(each a"Party"and collectively the"Parties")enter into the following
grant contract to provide funding for Primary Health Care(PHC)services(the"Contract").
This Contract is a two-year renewal of Grantee's Contract#2016-048585, issued under the
Department of State Health Services ("DSHS") Request for Proposals #537-16-142081,
released April 1,2015 (the "RFP"). Due to administrative changes stemming from Senate
Bill 200, 84th Legislature (requiring consolidation of the Health and Human Services
System),all functions associated with the RFP have been transferred from DSHS to System
Agency pursuant to Texas Government Code, Section 531.0201.
This Contract restates the scope of work and substance of the RFP's resulting contract,
subject to System Agency's terms and conditions.
II. LEGAL AUTHORITY
This Contract is authorized by and in compliance with the provisions of the Primary Health
Care Services Act,H.B. 1844,Health and Safety Code Section 12.051 and Chapter 31,and
25 Texas Administrative Code, Chapter 39, Subchapter A.
III. DURATION
The Contract is effective on September 1,2017 and terminates on August 31,2019,unless
renewed, extended, or terminated pursuant to the terms and conditions of this Contract.
The System Agency, at its own discretion, may extend this Contract for one (1) one-year
term subject to terms and conditions mutually agreeable to both Parties.
IV.BUDGET
The total amount of this Contract will not exceed Two HUNDRED EIGHTY THOUSAND
DOLLARS($280,000.00)in state grant funds to be allocated as follows:
Fiscal Year(FY) Total State Funding
FY 2016 (September 1, 2015 through August 31, 2016) $70,000.00
FY 2017 (September 1, 2016 through August 31, 2017) $70,000.00
FY 2018 (September 1, 2017 through August 31, 2018) $70,000.00
FY 2019 (September 1, 2018 through August 31, 2019) $70,000.00
System Agency Contract No.2016-048585-002
Page 1 of 4
v.2.13
3.1.17
All expenditures under the Contract will be in accordance with ATTACHMENT B,BUDGET.
All payments shall be made on a cost reimbursement basis.
V. NOTICE TO PROCEED
Funding for this Contract is dependent on State Appropriations. No FY 2018 work may
begin and no charges may be incurred until the System Agency issues a written notice to
proceed to Grantee. This Notice to Proceed may include an Amended or Ratified Budget
which will be incorporated into this Contract by a subsequent Amendment, as necessary.
VI.REPORTING REQUIREMENTS
Grantee shall submit monthly,quarterly, and annual programmatic reports and/or financial
vouchers/reports as required in Attachment A--Statement of Work and the PHC Policy
Manual, as amended. Other data and/or reports deemed necessary by System Agency may
be required, upon reasonable notice to Grantee.
VII. CONTRACT REPRESENTATIVES
The following will act as the Representative authorized to administer activities under this
Contract on behalf of their respective Party.
System Agency
Health and Human Services Commission
4900 North Lamar Blvd.
Austin, Texas, 78751
Attention: Vicki Magee, Certified Texas Contract Manager
Grantee
City of Port Arthur
449 Austin Avenue
Port Arthur,TX 77640
Attention: Brian McDougal, City Manager
VIII. LEGAL NOTICES
Any legal notice required under this Contract shall be deemed delivered when deposited by
the System Agency either in the United States mail, postage paid, certified, return receipt
requested; or with a common carrier,overnight, signature required,to the appropriate address
below:
System Agency Contract No.2016-048585-002
Page 2 of 4
System Agency
Charles Smith
Executive Commissioner
Health and Human Services Commission
PO Box 13247
Austin, Texas 78711-3247
With Required Copy to:
Karen Ray
Chief Counsel
P.O. Box 13247
Austin, Texas 78711-3247
Fax: (512)424-6586
Grantee
City of Port Arthur
449 Austin Avenue
Port Arthur, TX 77640
Attention: Brian McDougal, City Manager
Notice given by Grantee will be deemed effective when received by the System Agency.
Either Party may change its address for notice by written notice to the other Party.
SIGNATURE PAGE FOLLOWS
System Agency Contract No.2016-048585-002
Page 3 of 4
SIGNATURE PAGE FOR SYSTEM AGENCY CONTRACT No.2016-048585-002
SYSTEM AGENCY GRANTEE
Lesley French Name: Brian McDougal
Associate Commissioner Title: City Manager
Date of execution: Date of execution:
THE FOLLOWING ATTACHMENTS TO SYSTEM AGENCY CONTRACT NO. 2016-048585-002 ARE
HEREBY INCORPORATED BY REFERENCE:
ATTACHMENT A—STATEMENT OF WORK
ATTACHMENT B—BUDGET
ATTACHMENT C—UNIFORM TERMS AND CONDITIONS
ATTACHMENT D—SPECIAL CONDITIONS
ATTACHMENT E—GENERAL AFFIRMATIONS
ATTACHMENT F—DATA USE AGREEMENT
ATTACHMENT G—SYSTEM AGENCY SOLICITATION NO.537-16-142081
ATTACHMENT H—GRANTEE'S FY 2018 AND 2019 RENEWAL APPLICATION
ATTACHMENT I-SUPPLEMENTAL CONDITIONS
ATTACHMENTS FOLLOW
System Agency Contract No.2016-048585-002
Page 4 of 4
Attachment F — Data Use Agreement
HHS Contract No.2016-048585-002
DATA USE AGREEMENT
BETWEEN THE
TEXAS HEALTH AND HUMAN SERVICES ENTERPRISE
AND
City of Port Arthur("CONTRACTOR")
This Data Use Agreement("DUA"),effective as of the date signed below("Effective Date"),
is entered into by and between the Texas Health and Human Services Enterprise agency Health and
Human Services Commission("HHS")and City of Port Arthur ("CONTRACTOR"),and
incorporated into the terms of HHS Contract No.2016-048585-002,in Travis County,Texas(the
"Base Contract").
ARTICLE 1.PURPOSE; APPLICABILITY; ORDER OF PRECEDENCE
ATTACHMENT 1. The purpose of this DUA is to facilitate creation, receipt, maintenance,
use, disclosure or access to Confidential Information with CONTRACTOR, and describe
CONTRACTOR's rights and obligations with respect to the Confidential Information
and the limited purposes for which the CONTRACTOR may create, receive, maintain, use,
disclose or have access to Confidential Information. 45 CFR 164.504(e)(1)-(3) This DUA
also describes HHS's remedies in the event of CONTRACTOR's noncompliance with
its obligations under this DUA. This DUA applies to both Business Associates and contractors who
are not Business Associates who create, receive, maintain, use, disclose or have access to Confidential
Information on behalf of HHS,its programs or clients as described in the Base Contract.
As of the Effective Date of this DUA, if any provision of the Base Contract, including any General
Provisions or Uniform Terms and Conditions,conflicts with this DUA,this DUA controls.
ARTICLE 2. DEFINITIONS
For the purposes of this DUA, capitalized, underlined terms have the meanings set forth in the
following: Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (42 U.S.C.
§1320d,et seq.)and regulations thereunder in 45 CFR Parts 160 and 164,including all amendments,regulations
and guidance issued thereafter;The Social Security Act,including Section 1137(42 U.S.C. §§ 1320b-7),Title
XVI of the Act;The Privacy Act of 1974,as amended by the Computer Matching and Privacy Protection Act
of 1988, 5 U.S.C. § 552a and regulations and guidance thereunder; Internal Revenue Code, Title 26 of the
United States Code and regulations and publications adopted under that code,including IRS Publication 1075;
OMB Memorandum 07-18;Texas Business and Commerce Code Ch.521;Texas Government Code,Ch.552,
and Texas Government Code§2054.1125. In addition,the following terms in this DUA are defined as follows:
"Authorized Purpose" means the specific purpose or purposes described in the Scope of Work of
the Base Contract for CONTRACTOR to fulfill its obligations under the Base Contract,or any other purpose
expressly authorized by HHS in writing in advance.
"Authorized User"means a Person:
(1) Who is authorized to create, receive, maintain, have access to, process, view, handle,
examine, interpret,or analyze Confidential Information pursuant to this DUA;
(2) For whom CONTRACTOR warrants and represents has a demonstrable need to create,
receive,maintain,use,disclose or have access to the Confidential Information; and
(3) Who has agreed in writing to be bound by the disclosure and use limitations pertaining to
the Confidential Information as required by this DUA.
HHS Data Use Agreement V.8.3 April 1,2015
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HHS Contract No.2016-043585-002
"Confidential Information" means any communication or record (whether oral, written,
electronically stored or transmitted,or in any other form)provided to or made available to CONTRACTOR or
that CONTRACTOR may create, receive, maintain, use, disclose or have access to on behalf of HHS that
consists of or includes any or all of the following:
(1) Client Information;
(2) Protected Health Information in any form including without limitation, Electronic
Protected Health Information or Unsecured Protected Health Information;
(3) Sensitive Personal Information defined by Texas Business and Commerce Code Ch. 521;
(4) Federal Tax Information;
(5) Personally Identifiable Information;
(6) Social Security Administration Data,including,without limitation,Medicaid information;
(7) All privileged work product;
(8) All information designated as confidential under the constitution and laws of the State of
Texas and of the United States,including the Texas Health&Safety Code and the Texas Public Information
Act,Texas Government Code, Chapter 552.
"Legally Authorized Representative" of the Individual, as defined by Texas law, including as
provided in 45 CFR 435.923(Medicaid);45 CFR 164.502(g)(1)(HIPAA);Tex.Occ.Code§ 151.002(6);Tex.
H.&S.Code§166.164;Estates Code Ch.752 and Texas Prob.Code§3.
ARTICLE 3.CONTRACTOR'S DUTIES REGARDING CONFIDENTIAL INFORMATION
Section 3.01 Obligations of CONTRACTOR
CONTRACTOR agrees that:
(A) CONTRACTOR will exercise reasonable care and no less than the same degree of care
CONTRACTOR uses to protect its own confidential, proprietary and trade secret information to prevent
any portion of the Confidential Information from being used in a manner that is not expressly an Authorized
Purpose under this DUA or as Required by Law.45 CFR 164.502(b)(1);45 CFR 164.514(d)
(B) CONTRACTOR will not,without HHS's prior written consent,disclose or allow access to
any portion of the Confidential Information to any Person or other entity, other than Authorized User's
Workforce or Subcontractors of CONTRACTOR who have completed training in confidentiality,privacy,
security and the importance of promptly reporting any Event or Breach to CONTRACTOR's management,
to carry out the Authorized Purpose or as Required by Law.
HHS, at its election, may assist CONTRACTOR in training and education on specific or unique
HHS processes, systems and/or requirements. CONTRACTOR will produce evidence of completed
training to HHS upon request.45 C.F.R. 164.308(a)(5)(i); Texas Health& Safety Code§181.101
(C) CONTRACTOR will establish,implement and maintain appropriate sanctions against any
member of its Workforce or Subcontractor who fails to comply with this DUA, the Base Contract or
applicable law.CONTRACTOR will maintain evidence of sanctions and produce it to HHS upon request.45
C.F.R. 164.308(a)(1)(ii)(C);164.530(e);164.410(b);164.530(b)(1)
(D) CONTRACTOR will not, without prior written approval of HHS, disclose or provide
access to any Confidential Information on the basis that such act is Required by Law without notifying
HHS so that HHS may have the opportunity to object to the disclosure or access and seek appropriate relief.
If HHS objects to such disclosure or access, CONTRACTOR will refrain from disclosing or providing
HHS Data Use Agreement V.8.3 April 1,2015
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I IHS Contract No.2016-048585-002
access to the Confidential Information until HHS has exhausted all alternatives for relief. 95 CFR
164.5 04(e)(2)(i i)(A)
(E) CONTRACTOR will not attempt to re-identify or further identify Confidential Information
or De-identified Information, or attempt to contact any Individuals whose records are contained in the
Confidential Information, except for an Authorized Purpose, without express written authorization from
HHS or as expressly permitted by the Base Contract. 45 CFR 164.502(d)(2)(i) and(ii) CONTRACTOR
will not engage in prohibited marketing or sale of Confidential Information. 45 CFR 164.501,
164.508(a)(3)and(4); Texas Health&Safety Code Ch. 181.002
(F) CONTRACTOR will not permit, or enter into any agreement with a Subcontractor to,
create, receive, maintain, use, disclose, have access to or transmit Confidential Information, on behalf of
CONTRACTOR without requiring that Subcontractor first execute the Form Subcontractor Agreement,
Attachment 1, which ensures that the Subcontractor will comply with the identical terms, conditions,
safeguards and restrictions as contained in this DUA for PHI and any other relevant Confidential
Information and which permits more strict limitations; and 45 CFR 164.502(e)(1)(1)(ii); 164.504(e)(1)(1)
and(2)
(G) CONTRACTOR is directly responsible for compliance with, and enforcement of, all
conditions for creation,maintenance, use,disclosure,transmission and Destruction of Confidential Information
and the acts or omissions of Subcontractors as may be reasonably necessary to prevent unauthorized use. 45
CFR 164.504(e)(5);42 CFR 431.300,et seq.
(H) If CONTRACTOR maintains PHI in a Designated Record Set,CONTRACTOR will make
PHI available to HHS in a Designated Record Set or, as directed by HHS, provide PHI to the Individual,
or Legally Authorized Representative of the Individual who is requesting PHI in compliance with the
requirements of the HIPAA Privacy Regulations. CONTRACTOR will make other Confidential
Information in CONTRACTOR's possession available pursuant to the requirements of HIPAA or other
applicable law upon a determination of a Breach of Unsecured PHI as defined in HIPAA. 45 CFR
164.524and 164.504(e)(2)(ii)(E)
(I) CONTRACTOR will make PHI as required by HIPAA available to HHS for amendment
and incorporate any amendments to this information that HHS directs or agrees to pursuant to the HIPAA.
45 CFR 164.504(e)(2)(ii)(E) and(F)
(J) CONTRACTOR will document and make available to HHS the PHI required to provide
access, an accounting of disclosures or amendment in compliance with the requirements of the HIPAA
Privacy Regulations.45 CFR 164.504(e)(2)(ii)(G) and 164.528
(K) If CONTRACTOR receives a request for access,amendment or accounting of PHI by any
Individual subject to this DUA, it will promptly forward the request to HHS; however, if it would violate
HIPAA to forward the request, CONTRACTOR will promptly notify HHS of the request and of
CONTRACTOR's response. Unless CONTRACTOR is prohibited by law from forwarding a request,HHS
will respond to all such requests, unless HHS has given prior written consent for CONTRACTOR to
respond to and account for all such requests. 45 CFR 164.504(e)(2)
(L) CONTRACTOR will provide, and will cause its Subcontractors and agents to provide,to
HHS periodic written certifications of compliance with controls and provisions relating to information
privacy, security and breach notification,including without limitation information related to data transfers
and the handling and disposal of Confidential Information.45 CFR 164.308;164.530(c);1 TAC 202
(M) Except as otherwise limited by this DUA, the Base Contract, or law applicable to the
Confidential Information, CONTRACTOR may use or disclose PHI for the proper management and
administration of CONTRACTOR or to carry out CONTRACTOR's legal responsibilities if: 45 CFR
164.504(e)(ii)(1)(A)
HHS Data Use Agreement V.8.3 April 1,2015
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HHS Contract No.2016-048585-002
(1) Disclosure is Required by Law, provided that CONTRACTOR complies with Section
3.01(D);
(2) CONTRACTOR obtains reasonable assurances from the Person to whom the information
is disclosed that the Person will:
(a)Maintain the confidentiality of the Confidential Information in accordance with this DUA;
(b)Use or further disclose the information only as Required by Law or for the Authorized Purpose
for which it was disclosed to the Person;and
(c)Notify CONTRACTOR in accordance with Section 4.01 of any Event or Breach of Confidential
Information of which the Person discovers or should have discovered with the exercise of
reasonable diligence. 45 CFR 164.504(e)(4)(ii)(B)
(N) Except as otherwise limited by this DUA,CONTRACTOR will,if requested by HHS,use
PHI to provide data aggregation services to HHS,as that term is defined in the HIPAA,45 C.F.R. §164.501
and permitted by HIPAA. 45 CFR 164.504(e)(2)(1)(B)
(0) CONTRACTOR will, on the termination or expiration of this DUA or the Base Contract,
at its expense, return to HHS or Destroy, at HHS's election, and to the extent reasonably feasible and
permissible by law, all Confidential Information received from HHS or created or maintained by
CONTRACTOR or any of CONTRACTOR's agents or Subcontractors on HHS's behalf if that data
contains Confidential Information.CONTRACTOR will certify in writing to HHS that all the Confidential
Information that has been created,received,maintained,used by or disclosed to CONTRACTOR,has been
Destroyed or returned to HHS, and that CONTRACTOR and its agents and Subcontractors have retained
no copies thereof. Notwithstanding the foregoing, CONTRACTOR acknowledges and agrees that it may
not Destroy any Confidential Information if federal or state law, or HHS record retention policy or a
litigation hold notice prohibits such Destruction. If such return or Destruction is not reasonably feasible,
or is impermissible by law, CONTRACTOR will immediately notify HHS of the reasons such return or
Destruction is not feasible,and agree to extend indefinitely the protections of this DUA to the Confidential
Information and limit its further uses and disclosures to the purposes that make the return of the Confidential
Information not feasible for as long as CONTRACTOR maintains such Confidential Information.45 CFR
164.5 04(e)(2)(i i)(J)
(P) CONTRACTOR will create, maintain, use, disclose, transmit or Destroy Confidential
Information in a secure fashion that protects against any reasonably anticipated threats or hazards to the
security or integrity of such information or unauthorized uses. 45 CFR 164.306;164.530(c)
(Q) If CONTRACTOR accesses,transmits, stores,and/or maintains Confidential Information,
CONTRACTOR will complete and return to HHS at infosecuritya,hhsc.state.tx.us the HHS information
security and privacy initial inquiry (SPI) at Attachment 2 . The SPI identifies basic privacy and security
controls with which CONTRACTOR must comply to protect HHS Confidential Information.
CONTRACTOR will comply with periodic security controls compliance assessment and monitoring by
HHS as required by state and federal law,based on the type of Confidential Information CONTRACTOR
creates, receives, maintains, uses, discloses or has access to and the Authorized Purpose and level of risk.
CONTRACTOR's security controls will be based on the National Institute of Standards and Technology
(NIST)Special Publication 800-53. CONTRACTOR will update its security controls assessment whenever
there are significant changes in security controls for HHS Confidential Information and will provide the
updated document to HHS. HHS also reserves the right to request updates as needed to satisfy state and
federal monitoring requirements. 45 CFR 164.306
(R) CONTRACTOR will establish, implement and maintain any and all appropriate
procedural,administrative,physical and technical safeguards to preserve and maintain the confidentiality,
integrity, and availability of the Confidential Information, and with respect to PHI, as described in the
HHS Data Use Agreement V.8.3 April 1,2015
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HHS Contract No.2016-048585-002.
HIPAA Privacy and Security Regulations, or other applicable laws or regulations relating to Confidential
Information, to prevent any unauthorized use or disclosure of Confidential Information as long as
CONTRACTOR has such Confidential Information in its actual or constructive possession. 45 CFR
164.308 (administrative safeguards); 164.310 (physical safeguards); 164.312 (technical safeguards);
164.530(c)(privacy safeguards)
(S) CONTRACTOR will designate and identify,subject to HHS approval,a Person or Persons,
as Privacy Official 45 CFR 164.530(a)(1) and Information Security Official, each of whom is authorized
to act on behalf of CONTRACTOR and is responsible for the development and implementation of the
privacy and security requirements in this DUA. CONTRACTOR will provide name and current address,
phone number and e-mail address for such designated officials to HHS upon execution of this DUA and
prior to any change. 45 CFR 164.308(a)(2)
(T) CONTRACTOR represents and warrants that its Authorized Users each have a
demonstrated need to know and have access to Confidential Information solely to the minimum extent
necessary to accomplish the Authorized Purpose pursuant to this DUA and the Base Contract,and further,
that each has agreed in writing to be bound by the disclosure and use limitations pertaining to the
Confidential Information contained in this DUA. 45 CFR 164.502;164.514(d)
(U) CONTRACTOR and its Subcontractors will maintain an updated, complete, accurate and
numbered list of Authorized Users,their signatures,titles and the date they agreed to be bound by the terms
of this DUA, at all times and supply it to HHS,as directed, upon request.
(V) CONTRACTOR will implement, update as necessary, and document reasonable and
appropriate policies and procedures for privacy, security and Breach of Confidential Information and an
incident response plan for an Event or Breach, to comply with the privacy, security and breach notice
requirements of this DUA prior to conducting work under the DUA.45 CFR 164.308;164.316;164.514(d);
164.530(1)(1)
(W) CONTRACTOR will produce copies of its information security and privacy policies and
procedures and records relating to the use or disclosure of Confidential Information received from,created
by, or received, used or disclosed by CONTRACTOR on behalf of HHS for HHS's review and approval
within 30 days of execution of this DUA and upon request by HHS the following business day or other
agreed upon time frame. 45 CFR 164.308;164.514(d)
(X) CONTRACTOR will make available to HHS any information HHS requires to fulfill HHS's
obligations to provide access to, or copies of, PHI in accordance with HIPAA and other applicable laws and
regulations relating to Confidential Information. CONTRACTOR will provide such information in a time and
manner reasonably agreed upon or as designated by the Secretary, or other federal or state law. 45 CFR
164.504(e)(2)(i)(1)
(Y) CONTRACTOR will only conduct secure transmissions of Confidential Information
whether in paper,oral or electronic form. A secure transmission of electronic Confidential Information in
motion includes secure File Transfer Protocol (SFTP) or Encryption at an appropriate level or otherwise
protected as required by rule,regulation or law. HHS Confidential Information at rest requires Encryption
unless there is adequate administrative, technical, and physical security, or as otherwise protected as
required by rule, regulation or law. All electronic data transfer and communications of Confidential
Information will be through secure systems. Proof of system, media or device security and/or Encryption
must be produced to HHS no later than 48 hours after HHS's written request in response to a compliance
investigation,audit or the Discovery of an Event or Breach. Otherwise,requested production of such proof
will be made as agreed upon by the parties. De-identification of HHS Confidential Information is a means
of security. With respect to de-identification of PHI, "secure" means de-identified according to HIPAA
Privacy standards and regulatory guidance.45 CFR 164.312; 164.530(d)
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HHS Contract No. 2016-043585-002
(Z) CONTRACTOR will comply with the following laws and standards if applicable to the type of
Confidential Information and Contractor's Authorized Purpose:
• Title 1, Part 10, Chapter 202, Subchapter B,Texas Administrative Code;
• The Privacy Act of 1974;
• OMB Memorandum 07-16;
• The Federal Information Security Management Act of 2002(FISMA);
• The Health Insurance Portability and Accountability Act of 1996 (HIPAA) as defined in the
DUA;
• Internal Revenue Publication 1075 —Tax Information Security Guidelines for Federal, State
and Local Agencies;
• National Institute of Standards and Technology(NIST)Special Publication 800-66 Revision 1
— An Introductory Resource Guide for Implementing the Health Insurance Portability and
Accountability Act(HIPAA)Security Rule;
• NIST Special Publications 800-53 and 800-53A—Recommended Security Controls for Federal
Information Systems and Organizations,as currently revised;
• NIST Special Publication 800-47 — Security Guide for Interconnecting Information
Technology Systems;
• NIST Special Publication 800-88,Guidelines for Media Sanitization;
• NIST Special Publication 800-111,Guide to Storage of Encryption Technologies for End User
Devices containing PHI; and
• Any other State or Federal law, regulation, or administrative rule relating to the specific HHS
program area that CONTRACTOR supports on behalf of HHS.
ARTICLE 4. BREACH NOTICE,REPORTING AND CORRECTION REQUIREMENTS
Section 4.01. Breach or Event Notification to HHS. 45 CFR 164.400-414
(A) CONTRACTOR will cooperate fully with HHS in investigating, mitigating to the extent
practicable and issuing notifications directed by HHS, for any Event or Breach of Confidential
Information to the extent and in the manner determined by HHS.
(B) CONTRACTOR'S obligation begins at the Discovery of an Event or Breach and continues
as long as related activity continues,until all effects of the Event are mitigated to HHS's satisfaction
(the"incident response period").45 CFR 164.404
(C) Breach Notice:
1. Initial Notice.
a. For federal information, including without limitation, Federal Tax Information, Social Security
Administration Data, and Medicaid Client Information,within the first,consecutive clock hour of
Discovery, and for all other types of Confidential Information not more than 24 hours after
Discovery, or in a timeframe otherwise approved by HHS in writing, initially report to HHS's
Privacy and Security Officers via email at: privacv(a,HHSC.state.tx.us and to the HHS division
responsible for this DUA; and IRS Publication 1075; Privacy Act of 1974, as amended by the
Computer Matching and Privacy Protection Act of 1988, 5 U.S.C. §552a; OMB Memorandum
07-16 as cited in HHSC-CMS Contracts for information exchange.
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HHS Contract No.2016-048585-002
b.Report all information reasonably available to CONTRACTOR about the Event or Breach of the
privacy or security of Confidential Information. 45 CFR 164.410
c. Name, and provide contact information to HHS for, CONTRACTOR's single point of contact
who will communicate with HHS both on and off business hours during the incident response
period.
2. 48-Hour Formal Notice. No later than 48 consecutive clock hours after Discovery, or a
time within which Discovery reasonably should have been made by CONTRACTOR of an Event
or Breach of Confidential Information, provide formal notification to the State, including all
reasonably available information about the Event or Breach, and CONTRACTOR's investigation,
including without limitation and to the extent available: For(a) - (m) below: 45 CFR 164.400-
414
a. The date the Event or Breach occurred;
b. The date of CONTRACTOR's and,if applicable, Subcontractor's Discovery;
c.A brief description of the Event or Breach; including how it occurred and who is responsible(or
hypotheses, if not yet determined);
d.A brief description of CONTRACTOR's investigation and the status of the investigation;
e. A description of the types and amount of Confidential Information involved;
f. Identification of and number of all Individuals reasonably believed to be affected, including first
and last name of the individual and if applicable the,Legally authorized representative,last known
address,age,telephone number,and email address if it is a preferred contact method,to the extent
known or can be reasonably determined by CONTRACTOR at that time;
g. CONTRACTOR's initial risk assessment of the Event or Breach demonstrating whether
individual or other notices are required by applicable law or this DUA for HHS approval,including
an analysis of whether there is a low probability of compromise of the Confidential Information or
whether any legal exceptions to notification apply;
h. CONTRACTOR's recommendation for HHS's approval as to the steps Individuals and/or
CONTRACTOR on behalf of Individuals, should take to protect the Individuals from potential
harm, including without limitation CONTRACTOR's provision of notifications,credit protection,
claims monitoring,and any specific protections for a Legally Authorized Representative to take on
behalf of an Individual with special capacity or circumstances;
i. The steps CONTRACTOR has taken to mitigate the harm or potential harm caused (including
without limitation the provision of sufficient resources to mitigate);
j. The steps CONTRACTOR has taken, or will take, to prevent or reduce the likelihood of
recurrence of a similar Event or Breach;
k. Identify, describe or estimate of the Persons, Workforce, Subcontractor,or Individuals and any
law enforcement that may be involved in the Event or Breach;
1. A reasonable schedule for CONTRACTOR to provide regular updates to the foregoing in the
future for response to the Event or Breach, but no less than every three (3) business days or as
otherwise directed by HHS,including information about risk estimations,reporting,notification,if
any, mitigation, corrective action, root cause analysis and when such activities are expected to be
completed; and
m. Any reasonably available, pertinent information, documents or reports related to an Event or
Breach that HHS requests following Discovery.
HHS Data Use Agreement V.8.3 April 1,2015
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HHS Contract No. 2016-043585-002
Section 4.02 Investigation,Response and Mitigation. For A-F below: 45 CFR 164.308, 310
and 312;164.530
(A) CONTRACTOR will immediately conduct a full and complete investigation, respond to
the Event or Breach, commit necessary and appropriate staff and resources to expeditiously
respond,and report as required to and by HHS for incident response purposes and for purposes of
HHS's compliance with report and notification requirements,to the satisfaction of HHS.
(B) CONTRACTOR will complete or participate in a risk assessment as directed by HHS
following an Event or Breach,and provide the final assessment,corrective actions and mitigations
to HHS for review and approval.
(C) CONTRACTOR will fully cooperate with HHS to respond to inquiries and/or proceedings
by state and federal authorities, Persons and/or Individuals about the Event or Breach.
(D) CONTRACTOR will fully cooperate with HHS's efforts to seek appropriate injunctive
relief or otherwise prevent or curtail such Event or Breach,or to recover or protect any Confidential
Information, including complying with reasonable corrective action or measures, as specified by
HHS in a Corrective Action Plan if directed by HHS under the Base Contract.
Section 4.03 Breach Notification to Individuals and Reporting to Authorities. Tex. Bus. &
Comm. Code§521.053;45 CFR 164.404(Individuals), 164.406(Media); 164.408(Authorities)
(A) HHS may direct CONTRACTOR to provide Breach notification to Individuals,regulators
or third-parties, as specified by HHS following a Breach.
(B) CONTRACTOR must obtain HHS's prior written approval of the time,manner and content
of any notification to Individuals, regulators or third-parties, or any notice required by other state
or federal authorities. Notice letters will be in CONTRACTOR's name and on CONTRACTOR's
letterhead, unless otherwise directed by HHS, and will contain contact information, including the
name and title of CONTRACTOR's representative, an email address and a toll-free telephone
number,for the Individual to obtain additional information.
(C) CONTRACTOR will provide HHS with copies of distributed and approved
communications.
(D) CONTRACTOR will have the burden of demonstrating to the satisfaction of HHS that any
notification required by HHS was timely made. If there are delays outside of CONTRACTOR's
control,CONTRACTOR will provide written documentation of the reasons for the delay.
(E) If HHS delegates notice requirements to CONTRACTOR,HHS shall, in the time and manner
reasonably requested by CONTRACTOR, cooperate and assist with CONTRACTOR's
information requests in order to make such notifications and reports.
ARTICLE 5. SCOPE OF WORK
Scope of Work means the services and deliverables to be performed or provided by CONTRACTOR,
or on behalf of CONTRACTOR by its Subcontractors or agents for HHS that are described in detail in the Base
Contract. The Scope of Work, including any future amendments thereto, is incorporated by reference in this
DUA as if set out word-for-word herein.
ARTICLE 6. GENERAL PROVISIONS
Section 6.01 Ownership of Confidential Information
HHS Data Use Agreement V.8.3 April 1,2015
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HHS Contract No.2016-048585-002
CONTRACTOR acknowledges and agrees that the Confidential Information is and will remain the
property of HHS. CONTRACTOR agrees it acquires no title or rights to the Confidential Information.
Section 6.02 HHS Commitment and Obligations
HHS will not request CONTRACTOR to create,maintain,transmit,use or disclose PHI in any manner that
would not be permissible under applicable law if done by HHS.
Section 6.03 HHS Right to Inspection
At any time upon reasonable notice to CONTRACTOR,or if HHS determines that CONTRACTOR
has violated this DUA,HHS,directly or through its agent,will have the right to inspect the facilities,systems,
books and records of CONTRACTOR to monitor compliance with this DUA. For purposes of this subsection,
HHS's agent(s) include, without limitation, the HHS Office of the Inspector General or the Office of the
Attorney General of Texas,outside consultants or legal counsel or other designee.
Section 6.04 Term; Termination of DUA;Survival
This DUA will be effective on the date on which CONTRACTOR executes the DUA, and will
terminate upon termination of the Base Contract and as set forth herein . If the Base Contract is extended or
amended,this DUA is updated automatically concurrent with such extension or amendment.
(A) HHS may immediately terminate this DUA and Base Contract upon a material violation of
this DUA.
(B) Termination or Expiration of this DUA will not relieve CONTRACTOR of its obligation
to return or Destroy the Confidential Information as set forth in this DUA and to continue to safeguard the
Confidential Information until such time as determined by HHS.
(D) If HHS determines that CONTRACTOR has violated a material term of this DUA; HHS
may in its sole discretion:
1. Exercise any of its rights including but not limited to reports, access and inspection under
this DUA and/or the Base Contract; or
2. Require CONTRACTOR to submit to a corrective action plan, including a plan for
monitoring and plan for reporting, as HHS may determine necessary to maintain compliance with
this DUA; or
3. Provide CONTRACTOR with a reasonable period to cure the violation as determined by
HHS;or
4. Terminate the DUA and Base Contract immediately,and seek relief in a court of competent
jurisdiction in Travis County,Texas.
Before exercising any of these options, HHS will provide written notice to CONTRACTOR
describing the violation and the action it intends to take.
(E) If neither termination nor cure is feasible, HHS shall report the violation to the Secretary.
(F) The duties of CONTRACTOR or its Subcontractor under this DUA survive the expiration or
termination of this DUA until all the Confidential Information is Destroyed or returned to HHS,as required
by this DUA.
Section 6.05 Governing Law, Venue and Litigation
HHS Data Use Agreement V.8.3 April 1,2015
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HI IS Contract No.2016-043585-002
(A) The validity,construction and performance of this DUA and the legal relations among the
Parties to this DUA will be governed by and construed in accordance with the laws of the State of Texas.
(B) The Parties agree that the courts of Travis County, Texas, will be the exclusive venue for
any litigation, special proceeding or other proceeding as between the parties that may be brought, or arise
out of,or in connection with,or by reason of this DUA.
Section 6.06 Injunctive Relief
(A) CONTRACTOR acknowledges and agrees that HHS may suffer irreparable injury if
CONTRACTOR or its Subcontractor fails to comply with any of the terms of this DUA with respect to the
Confidential Information or a provision of HIPAA or other laws or regulations applicable to Confidential
Information.
(B) CONTRACTOR further agrees that monetary damages may be inadequate to compensate
HHS for CONTRACTOR's or its Subcontractor's failure to comply. Accordingly,CONTRACTOR agrees
that HHS will, in addition to any other remedies available to it at law or in equity, be entitled to seek
injunctive relief without posting a bond and without the necessity of demonstrating actual damages, to
enforce the terms of this DUA.
Section 6.07 Indemnification
To the extent permitted by law, CONTRACTOR will indemnify,defend and hold harmless HHS and its
respective Executive Commissioner,employees, Subcontractors,agents(including other state agencies acting
on behalf of HHS) or other members of its Workforce (each of the foregoing hereinafter referred to as
"Indemnified Party") against all actual and direct losses suffered by the Indemnified Party and all liability to
third parties arising from or in connection with any breach of this DUA or from any acts or omissions related
to this DUA by CONTRACTOR or its employees, directors, officers, Subcontractors, or agents or other
members of its Workforce. The duty to indemnify, defend and hold harmless is independent of the duty to
insure and continues to apply even in the event insurance coverage required, if any, in the DUA or Base
Contract is denied,or coverage rights are reserved by any insurance carrier. Upon demand, CONTRACTOR
will reimburse HHS for any and all losses,liabilities,lost profits,fines,penalties,costs or expenses(including
reasonable attorneys' fees)which may for any reason be imposed upon any Indemnified Party by reason of any
suit,claim,action,proceeding or demand by any third party to the extent caused by and which results from the
CONTRACTOR's failure to meet any of its obligations under this DUA. To the extent permitted by law,
CONTRACTOR's obligation to defend,indemnify and hold harmless any Indemnified Party will survive the
expiration or termination of this DUA.
Section 6.08 Insurance
(A) CONTRACTOR represents and warrants that it maintains either self-insurance or
commercial insurancewith policy limits sufficient to cover any liability arising from any acts or omissions
by CONTRACTOR or its employees, directors, officers, Subcontractors, or agents or other members of its
Workforce under this DUA. CONTRACTOR warrants that HHS will be a loss payee and beneficiary for any
such claims. .
(B) CONTRACTOR will provide HHS with written proof that required insurance coverage is
in effect,at the request of HHS.
Section 6.09 Fees and Costs
Except as otherwise specified in this DUA or the Base Contract, including but not limited to
requirements to insure and/or indemnify HHS, if any legal action or other proceeding is brought for the
enforcement of this DUA, or because of an alleged dispute, contract violation, Event. Breach, default,
HHS Data Use Agreement V.8.3 April 1,2015
Page l0 of 11
HHS Contract No.2016-048585-002
misrepresentation,or injunctive action, in connection with any of the provisions of this DUA,each party will
bear their own legal expenses and the other cost incurred in that action or proceeding.
Section 6.10 Entirety of the Contract
This Data Use Agreement is incorporated by reference into the Base Contract and,together with the
Base Contract, constitutes the entire agreement between the parties. No change, waiver, or discharge of
obligations arising under those documents will be valid unless in writing and executed by the party against
whom such change,waiver,or discharge is sought to be enforced.
Section 6.11 Automatic Amendment and Interpretation
Upon the effective date of any amendment or issuance of additional regulations to HIPAA, or any
other law applicable to Confidential Information, this DUA will automatically be amended so that the
obligations imposed on HHS and/or CONTRACTOR remain in compliance with such requirements. Any
ambiguity in this DUA will be resolved in favor of a meaning that permits HHS and CONTRACTOR to comply
with HIPAA or any other law applicable to Confidential Information.
ARTICLE 7. AUTHORITY To EXECUTE
The Parties have executed this DUA in their capacities as stated below with authority to bind their
organizations on the dates set forth by their signatures.
IN WITNESS HEREOF, HHS and CONTRACTOR have each caused this DUA to be signed and
delivered by its duly authorized representative:
TEXAS HEALTH AND HUMAN SERVICES CONTRACTOR
BY: BY:
NAME: Lesley French NAME: Brian McDougal
TITLE: Associate Commissioner TITLE: City Manager
DATE: ,201 . DATE: ,201
1-11S Data Use Agreement V.8.3 April 1,2015
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HHS Contract No. 2016-048585-002
ATTACHMENT 1. SUBCONTRACTOR AGREEMENT FORM
HHS CONTRACT NUMBER
The DUA between HHS and CONTRACTOR establishes the permitted and required uses and disclosures
of Confidential Information by CONTRACTOR.
CONTRACTOR has subcontracted with
(SUBCONTRACTOR)for performance of duties on behalf of CONTACTOR which are subject to the
DUA. SUBCONTRACTOR acknowledges,understands and agrees to be bound by the identical terms
and conditions applicable to CONTRACTOR under the DUA, incorporated by reference in this
Agreement,with respect to HHS Confidential Information. CONTRACTOR and SUBCONTRACTOR
agree that HHS is a third-party beneficiary to applicable provisions of the subcontract.
HHS has the right but not the obligation to review or approve the terms and conditions of the subcontract
by virtue of this Subcontractor Agreement Form.
CONTRACTOR and SUBCONTRACTOR assure HHS that any Breach or Event as defined by the DUA
that SUBCONTRACTOR Discovers will be reported to HHS by CONTRACTOR in the time, manner
and content required by the DUA.
If CONTRACTOR knows or should have known in the exercise of reasonable diligence of a pattern of
activity or practice by SUBCONTRACTOR that constitutes a material breach or violation of the DUA or
the SUBCONTRACTOR's obligations CONTRACTOR will:
1. Take reasonable steps to cure the violation or end the violation,as applicable;
2. If the steps are unsuccessful,terminate the contract or arrangement with SUBCONTRACTOR,if
feasible;
3. Notify HHS immediately upon reasonably discovery of the pattern of activity or practice of
SUBCONTRACTOR that constitutes a material breach or violation of the DUA and keep HHS
reasonably and regularly informed about steps CONTRACTOR is taking to cure or end the
violation or terminate SUBCONTACTOR's contract or arrangement.
This Subcontractor Agreement Form is executed by the parties in their capacities indicated below.
CONTRACTOR SUBCONTRACTOR
BY: BY:
NAME: Brian McDougal NAME:
TITLE: City Manager TITLE:
DATE ,201 . DATE:
HHS Data Use Agreement V.8.3 HIPAA Omnibus Compliant April 1,2015
Page 2 of 11
Attachment A — Statement of Work
ATTACHMENT A
STATEMENT OF WORK
GRANTEE RESPONSIBILITIES
Grantee will:
A. Provide comprehensive preventive and primary health care (PHC) services to Texas
residents with a gross family income at or below 200 percent of the federal poverty
level (FPL). Grantee shall provide the following priority services: diagnosis and
treatment, emergency medical services, family planning services, preventive health
services, including immunizations, health education, and laboratory, x-ray, nuclear
medicine, or other appropriate diagnostic services. In addition to priority services,
Grantee may provide the following optional PHC services: nutrition services, health
screening, home health care, dental care, transportation, prescription drugs,
environmental health,podiatry, and social services.
B. Provide services in accordance with this Contract, as amended, and the following
documents which are incorporated herein by reference and made a part of this Contract:
1. Attachment G--System Agency Solicitation No. 537-16-142081;
2. Attachment H--Grantee's FY 2018 and 2019 Renewal Application;
3. Grantee's Response to Solicitation No. 537-16-142081;
4. HHSC Primary Health Care Program Policy Manual, as amended;
5. Department of State Health Services Standards for Public Health Clinic
Services, as amended; and
6. HHSC Quality Management Review Policy and Procedures, as amended.
C. Screen all individuals considered for the PHC program to determine eligibility using a
System Agency-approved screening process in accordance with the PHC Policy
Manual, as amended. Grantee may not alter System Agency eligibility forms or use
another eligibility form unless it is submitted to and approved by System Agency. For
an individual to receive PHC services,three(3) criteria shall be met:
1. Texas resident;
2. Gross family income at or below 200% of the adopted Federal Poverty Level
(FPL); and
3. Not eligible for other non-HHSC programs/benefits providing the same
services.
D. Provide information and supporting documentation as requested by System Agency to
conduct desk reviews to verify accurate reporting/billing for the PHC Program. Failure
to submit requested information in a timely manner may result in sanctions as
authorized by the contract. If Grantee's desk review results in a finding of
misappropriation of System Agency PHC co-payment (co-pay) policy, Grantee shall
reimburse clients.
E. Notify System Agency in writing within thirty (30) days of the vacancy of a position
funded under this Contract. Grantee's contract award may be subject to a decrease
equal to the salary savings(salary and benefits)realized as a result of the vacancy.
ATTACHMENT A
STATEMENT OF WORK
F. Provide the following routine reports to System Agency in compliance with the dates
and conditions specified below:
Report Title Submission Frequency Due Date
PHC 225 Report Monthly The last business day of the month
Form following service; submit simultaneously
with the corresponding monthly Form
4116 Purchase Voucher.
Staff Training Plan Annually—within 45 days October 15
of the beginning of the
contract year
Grantee's Co-pay One time(beginning of September 30th
Policy and Fee contract year)
Schedule
Purchase Voucher Monthly The last business day of the month
(Form 4116) following service; submit simultaneously
with the corresponding complete
monthly report, PHC Form 225.
Financial Status Quarterly
Report (FSR)
Ql: September 1 —Nov 30 Q1: December 31
Q2: December 1 —February Q2: March 31
28/29
Q3: June 30
Q3: March 1 —May 31
Q4: October 15
Q4: June 1 —August 31
PHC 325 Annual Annually- within sixty October 30
Report (60) days after the end of
the contract term
1. PHC Form 225 (the Monthly Report): shall be sent to whsfinance(a�hhsc.state.tx.us
by the last business day of the month following the month of service. Grantee shall
provide requested data according to specified criteria(e.g., age, gender, number of
unduplicated clients, etc.) as detailed in PHC report Form 225. Vouchers (Form
4116) will not be paid until the corresponding monthly PHC Report Form 225 is
received and approved.
2. PHC 325 Annual Report: Grantee shall provide an annual program report to System
Agency no later than sixty(60)days after the end of the contract year. Grantee shall
provide requested data according to specified criteria (e.g., age, gender, race,
ATTACHMENT A
STATEMENT OF WORK
ethnicity, number of unduplicated clients, etc.) as detailed in PHC annual report
Form 325. Grantee shall email the report to the PHC mailbox
PHCReports@dshs.state.tx.us.
3. Financial Status Report(FSR): Grantee shall submit quarterly FSRs to the System
Agency Family and Social Services, Office of Women's Health and Education
Services, Contract Management Branch by the last business day of the month
following the end of each quarter during the Contract term. Vouchers(Form 4116)
for the corresponding month will not be processed until the quarterly FSR is
received, reviewed, and approved by System Agency. Grantee shall submit the
final FSR no later than forty-five(45)days following the end of the applicable term.
The final Voucher of the fiscal year will not be processed for payment until the
final FSR is received,reviewed, and approved by System Agency.
Failure to submit required reports in a timely manner may result in sanctions according
to provisions of this Contract.Voucher will not be paid until the corresponding monthly
report is received/approved.
G. Maintain data and management information systems that are compatible with accurate
reporting of contract performance.
H. Make reasonable efforts to investigate and apply for all other sources of third party
funding available to, or identified by, the patient before submitting System Agency
Program claims for allowable costs.
I. Implement policies and procedures for charging, billing, and collecting fees for
individual client services provided.These policies and procedures shall be reviewed by
Grantee's policy board or advisory committee.
J. Comply with the following guidelines regarding co-pays, as applicable. Grantee may
assess a co-pay from clients who receive services under this Contract, in accordance
with the PHC policy manual, as amended. Grantee may not deny a service due to
inability to pay. If Grantee charges client co-pay, Grantee shall adhere to the PHC fee
schedule in the PHC Policy Manual. Grantee shall submit the entity's FY 2018 and FY
2019 PHC client co-pay policy and fee schedules to the PHC mailbox
(primaryhealthcare@dshs.state.tx.us)for review and approval by September 30 of each
Contract year. The Grantee shall waive the fee if a client self-declares an inability to
pay.No client shall be denied services based on an inability to pay.
K. Report client co-pays as program income on the monthly Purchase Voucher Form 4116
and the quarterly Financial Status Report(FSR or Form 269a). See Appendices in the
System Agency PHC Policy and Procedure Manual, as amended, for the System
Agency client co-pay fee schedule.This section shall not be construed to apply to funds
raised by Grantee from fund-raising activities or donations. Fund raising includes
membership drives or special events used to raise program funds. Donations include
ATTACHMENT A
STATEMENT OF WORK
monies donated to the program by individuals and private groups, such as churches or
other organizations.
L. Make reasonable efforts to investigate and apply for all other sources of third party
funding available to,or identified by,the client before submitting claims for allowable
costs.
M. Include funds in the Travel budget category for a minimum of two (2) staff members
to attend up to two(2)trainings for two(2)days in Austin,Dallas/Fort Worth,Houston,
or San Antonio in the fall, spring, or summer of Fiscal Years 2018 and 2019.
N. Allow System Agency to conduct on-site quality assurance reviews as deemed
necessary by System Agency. Unsatisfactory review findings may result in
implementation of contract actions up to and including termination of the Contract.
O. Notify the System Agency Health and Developmental Services, Office of Specialty
Health Care Services, Contract Management Branch of any clinic site information
changes,e.g.,changes in contact person,hours of operation,address,National Provider
Identification (NPI) number, Texas Provider Identification (TPI) number, and the
closure,relocation, and/or opening of clinic site(s).
P. Initiate the purchase of all equipment approved in writing by System Agency by the
last business day of May in each Contract year.
Q. Comply with all applicable federal and state laws, rules, regulations, standards and
guidelines, as amended.
II. PERFORMANCE MEASURES
A. The following performance measures will be used to assess, in part, Grantee's
effectiveness in providing the services described in this Contract, without waiving the
enforceability of any of the other terms of this Contract:
1. For FY 2018,Grantee shall provide services to a minimum of 400 unduplicated
clients who live or receive services in the following county: Jefferson.
2. For FY 2019,Grantee shall provide services to a minimum of 400 unduplicated
clients who live or receive services in the following county: Jefferson.
B. System Agency will monitor Grantee's performance measure activity. If the number
of unduplicated clients served is less than that projected in Grantee's final approved
Application, Grantee's funding award may be subject to a decrease for the remainder
of the Contract year.
III. BILLING INSTRUCTIONS
ATTACHMENT A
STATEMENT OF WORK
A. Grantee shall submit requests for reimbursement of allowable PHC costs on a Purchase
Voucher (Form 4116) monthly by the last business day of the following of the month in
which the costs were incurred. Grantee shall submit a reimbursement request as a fmal
purchase voucher no later than forty-five (45) days following the end of the applicable
Contract year for costs encumbered on or before the last day of the Contract year.
Reimbursement requests received in System Agency offices more than forty-five (45)
calendar days following the end of the applicable Contract year will not be paid.
B. Grantee shall email Form 4116 to the System Agency Family and Social Services,
Women's Health and Education Services, Contract Management Branch at
whsfinance@hhsc.state.tx.us.
C. Grantee shall Form 4116 shall be submitted each month for actual program expenditures,
even if there are zero expenditures or if the contract budget limit has been reached.
D. Accept reimbursement or payment from System Agency and any applicable fees from
clients for clinical services as payment in full for services or goods provided to clients.
Grantee shall not seek additional reimbursement or payment for services or goods from
clients other than applicable fees for clinical health services.
E. System Agency shall distribute funds to maximize the delivery of authorized services to
eligible clients. System Agency will monitor Grantee's billing activity. Grantee may be
subject to contract amount decreases if Grantee's billing activity is less than projected.
F. Funds made available in the Contract year shall be used only for services performed during
the same Contract year. Funds that are not expended for services during that Contract year
cannot be used for services in any other period.
Remainder of Page Intentionally Left Blank.
Attachment B — Budget Documents
General Instructions for Completing Budget Forms
In preparing the budget,you must budget all costs that your organization will incur in
carrying out the Primary Health Care Program. Instructions for completing the budget
template follow:
Only respondents with cost reimbursement contracts need to
complete Forms F and F-1 through F-7.
* Enter the legal name of your organization in the space provided for"Legal
Name of Respondent"on the budget summary page. Doing so will
populate the budget category detail templates with the organization's
* Uompiete eacn oliaget category aetaii template. n a printery puaget
category detail template does not accommodate all items in your budget,
use the respective supplemental budget temples at the end of this
workbook. The total of each supplemental category detail budget template
will automatically populate to the last line of the respective primary budget
category template. The definition of each category can be found in the
DSHS Contractor's Financial Procedures Manual located at the following
web site:
http://www.dshs.state.tx.us/contracts
*After you complete each budget category detail template,go to the Budget
Summary.
* Distribute the total amount in column 1 in each budget category manually
amoung the various funding sources(columns 2 and 3).
* Refer to the table below the budget template table to verify that the
amounts distributed(Distribution Total)in each budget category equals the
"Budget Total"for each respective category. Next,verify that the overall
total of all distributions(Distribution Totals)equals the Budget Total.
* Fill all budget forms out in WHOLE DOLLARS.
Revised:11/18/2009
FORM F: BUDGET SUMMARY (REQUIRED)
Legal Name of Respondent: City of Port Arthur-FY 2018
Total Primary Health HHSC Share Patient Co-Pays
Budget Categories Care Budget Categorical Award To Be Collected
(1) (2) (3)
A. Personnel $34,596
B. Fringe Benefits $10,379
C. Travel $2,252
D. Equipment $0
E. Supplies $1,773
F. Contractual $21_,000
G. Other $0
H. Total Direct Costs $70,000 $0 $0
I. Indirect Costs $0
J Total(Sum of H and I) $70,000 SO $o-,
NOTE: The"Total Budget"amount for each Budget Category will have to be entered manually among columns 2 and 3. Enter amounts in whole
dollars. After amounts have been entered for each funding source,verify that the"Distribution Total"below equals the respective amount under
the"Total Budget"from column(11.
Budget Distribution Budget Budget Distribution Budget
Catetory Total Total Category Total Total
Check Totals For: Personnel $0 $34,596 Fringe Benefits $01 $10,379
Travel $0 $2,252 Equipment $0 $0
Supplies $0 $1,773 Contractual $0 $21,000
Other $0 $0 Indirect Costs $0 $0
TOTAL FOR: !Distribution Totals $0 Budget Total $70,000
Revised:11/18/2009
FORM F-1: PERSONNEL Budget Category Detail Form
Legal Name of Respondent: City of Port Arthur-FY 2018
PERSONNEL Certification or Total Average Number SalarylWages
Functional Title+Code Vacant License(Enter NA if Monthly of Requested for
=existing or P=rroposed YIN Justification FTEs not required) Salary/Wage Months Project
Medical Eligibility/Billing Clerk(E) N To perform eligibility,billing and 1 No $2,883.00 12 $34,596
reporting activities
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
TOTAL FROM PERSONNEL SUPPLEMENTAL BUDGET SHEETS SO
I SalaryWage Total $34,596
FRINGE BENEFITS Iltemize the elements of fringe benefits in the space below:
FICA 7.65%Insurance 22.35°
Fringe Benefit Rate% 30.00%
Fringe Benefits Total $10,379
Revised:7/6/2009
FORM F-2: TRAVEL Budget Category Detail Form
Legal Name of Respondent: (City of Port Arthur-FY 2018
Conference I Workshop Travel Costs
Description of Number of:
Conference/Workshop Justification LocationTravel Costs
City/State Days/Employees
Mileage
Airfare
2 employees 2 Meals $350
DSHS PHC Eligibility/Training To receive updates related to Eligibility/Billing Austin/TX
Days/2 Nights Lodging $520
Other Costs $200
Total $1,070
Mileage
Airfare
2 employees for 2 Meals $350
DSHS PHC Eligibility Training To receive updates related to Eligibility/Billing AustiniTX
Days/2 Nights Lodging $520
Other Costs $200
Total $1,070
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
TOTAL FROM TRAVEL SUPPLEMENTAL CONFERENCE/WORKSHOP BUDGET SHEETS $0
Total for Conference I Workshop Travel M ' l fl•/6/2009
Other I Local Travel Costs
Number of Mileage
Justification Miles Mileage Reimbursement Rate Cost Other Costs Total
(a) (b) (a)+(b)
Travel to Local schools,health fairs,etc.
200 $0.560 $112 $112
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
TOTAL FROM TRAVEL SUPPLEMENTAL OTHER/LOCAL TRAVEL COSTS BUDGET SHEE-S $0
Total for Other I Local Travel $112
Other l Local Travel Costs: $112 Conference I Workshop Travel Costs: $2,140 Total Travel Costs: $2,252
Indicate Policy Used: Respondents Travel Policy State of Texas Travel Policy
Revised:7/6/2009
FORM F-3: EQUIPMENT AND CONTROLLED ASSETS Budget Category
Detail Form
Legal Name of Respondent: City of Port Arthur-FY 2018
Itemize,describe, and justify below. Equipment is tangible nonexpendable personal property costing$5,000 or more and a useful life
of more than one year. Approved equipment must be purchased within 90 days of contract start date.
Number of
Description of Item Purpose&Justification Units Cost Per Unit Total
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$o
TOTAL FROM EQUIPMENT SUPPLEMENTAL BUDGET SHEETS $0
Total Amount Requested for Equipment: $0
Revised:7/6/2009
FORM F-4: SUPPLIES Budget Category Detail Form
Legal Name of Respondent: City of Port Arthur-FY 2018
Itemize and describe each supply item and provide an estimated quantity and cost if applicable. Provide a justification for each
supply item. Costs may be categorized by each general type-office, computer, medical,educational,etc. Supplies can be
consumable-paper, drugs,etc.,OR controlled assets costing $500 or more but less than $5,000-computers, printers, phones,
medical and lab equipment,etc.
Description of Item
lit applicable provide estimated quantity and cost(i.e#of boxes&cost/box)] Purpose&Justification Total Cost
Medical Supplies General medical supplies ,e.g., (syringes,cotton balls,gloves,
alcohol preps,depo-medrol,drape sheetS, etc $1,000
Office Supplies Pens, Copier paper, printer ink,folders, clip boards,etc $773
TOTAL FROM SUPPLIES SUPPLEMENTAL BUDGET SHEETS $0
Total Amount Requested for Supplies: $1,773
Revised:7/6/2009
FORM F-5: CONTRACTUAL Budget Category Detail Form
Legal Name of Respondent: City of Port Arthur-FY 2018
List contracts for medical services related to the scope of work that is to be provided by a third party. If a third party is not yet
identified,describe the service to be contracted and show contractors as"To Be Named." Justification for any contract that delegates
$100,000 or more of the scone of the project in the respondent's funding request,must be attached behind this form.
ME(HOD OF RATE OF
CONTRACTOR NAME DESCRIPTION OF SERVICES PAYMENT #of Months, PAYMENT(i.e.,
A enc or Individual) (Scope of Work) Justification (i.e.,Monthly, Hours,Units, hourly rate,unit TOTAL
(Agency ( P Hourly,Unit,Lump etc rate,lump sum
Sum) amount)
Lab Corp Laboratory Services To perform lab tests outside the
scope of the city's lab Monthly 12 $1,750.00 $21,000
$0
$0
$0
$0
$0
$0
$0
$0
TOTAL FROM CONTRACTUAL SUPPLEMENTAL BUDGET SHEETS SO
Total Amount Requested for CONTRACTUAL: $21,000
Revised:7/6/2009
FORM F-6: OTHER Budget Category Detail Form
Legal Name of Respondent: City of Port Arthur-FY 2018
Description of Item
[If applicable,include quantity and cost/quantity(i.e.#of units&cost per unit)] Purpose&Justification Total Cost
TOTAL FROM OTHER SUPPLEMENTAL BUDGET SHEETS $0
Total Amount Requested for Other: $0
Revised:7/6/2009
FORM F - 7 Indirect Costs
Legal Name of Respondent: I City of Port Arthur-FY 2018
Total amount of indirect costs allocable to the project: Amount:
Indirect costs are based on(mark the statement that is applicable):
The respondent's most recent indirect cost rate approved by a federal cognizant RATE:
agency or state single audit coordinating agency. Expired rate agreements are not BASE:
acceptable. Attach a copy of the rate agreement to this form(Form I.7 Indirect)
Applies only to governmental entities.The respondent's current central service cost RATE:
rate or indirect cost rate based on a rate proposal prepared in accordance with OMB TYPE:
Circular A-87. Attach a copy of Certification of Cost Allocation Plan or BASE:
Certification of Indirect Costs.
Note:Governmental units with only a Central Service Cost Rate must also include the
indirect cost of the governmental units department(i.e.HHSC). In this case indirect
costs will be comprised of central service costs(determined by applying the rate)and
the indirect costs of the governmental department. The allocation of indirect costs must
be addressed in Part V-Indirect Cost Allocation of the Cost Allocation Plan that is
submitted to HHSC.
A cost allocation plan. A cost allocation plan as specified in the DSHS Contractor's
Financial Procedures Manual(CFPM),Appendix A must be submitted to HHSC within
60 days of the contract start date. The CFPM is available on the following intemet web
link:http://www.dshs.state.tx.us/contracts/
GO TO PAGE 2(below)
Revised.7/6/2009
Page 2, FORM F - 7 Indirect Costs
If using an central service or indirect cost rate,identify the types of costs that are included(being allocated)in the rate:
Organizations that do not use an indirect cost rate and governmental entities with only a central service rate must identify the types of costs that will be
allocated as indirect costs and the methodology used to allocate these costs in the space provided below. The costs/methodology must also be disclosed in
Part V-Indirect Cost Allocation of the Cost Allocation Plan that is submitted to DSHS. Identify the types of costs that are being allocated as indirect costs,
the allocation methodology,and the allocation base:
Revised:7/6/2009
SUPPLEMENTAL FORMS INSTRUCTIONS
The budget templates(two per budget category)that follow are intended to supplement cost reimbursement
budgets when there are too many items to fit on the primary budget template. Applicants that have utilized all
the lines on the primary budget template must use the supplemental templates to list detail information for the
respective budget category. For example, after all the lines on the primary budget template for Personnel (tab
labled Form F- 1 Personnel)have been used, go to the supplemental template labled "Form F- 1 a Personnel
Supp" and if all the lines are used on this template, go to the next template labled "Form F- 1 b Personnel". The
amounts on each supplemental template will automatically total and the total from both templates will
automatically be inserted on the last line of the primary budget template.
The supplemental budget templates are:
Form F-1 Personnel Supplemental
Form F-2 Travel Supplemental
Form F-3 Equipment Supplemental
Form F-4 Supplies Supplemental
Form F-5 Contractual Supplemental
Form F-6 Other Supplemental
Revised: 7/6/2009
FORM F-1: PERSONNEL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur-FY 2018
PERSONNEL Certification or Total Average Number SalarylWages
Functional Title+Code VacantLicense(Enter NA d Monthly of Requested for
t
=existing or r= roposea YIN Justification I FTEs not required) SalarylWage Months Project
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
SalaryWage Total $0
Revised:7/6/2009
FORM F-1: PERSONNEL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur-FY 2018
PERSONNEL Certification or Total Average Number SalarylWages
Functional Title+Code VacantLicense(Enter Na if Monthly of Requested for
=hoisting or r=rroposeo YIN Justification FTE's not required) SalarylWage Months Project
so
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
SalaryWage Total $0
Revised:7/6/2009
FORM F-2: TRAVEL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur-FY 2018
Conference I Workshop Travel Costs
Description of Location Number of:
Conference/Workshop Justification (City,State) Days/Employees Travel Costs
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Total for Conference I Workshop Travel $0
'Other/Local Travel Costs I Revised:7/6/2009
Number of Mileage
Justification Miles Mileage Reimbursement Rate Cost Other Costs Total
(a) (b) (a)'(b)
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 so
$0 $0
Total for Other I Local Travel $0
Other(Local Travel Costs: $0 Conference I Workshop Travel Costs: $0 Total Travel Costs: $0
Revised:7/6/2009
FORM F-2: TRAVEL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur-FY 2018
Conference/Workshop Travel Costs
Description of Location Number of:
Conference/Workshop Justification (City,State) Days/Employees Travel Costs
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Total for Conference 1 Workshop Travel $0
'Other I Local Travel Costs I Revised:7/6/2009
Number of Mileage
Justification Miles Mileage Reimbursement Rate Cost Other Costs Total
(a) (b) (a)+(b)
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 SO
$0 SO
$0 SO
$0 SO
Total for Other I Local Travel $0
Other 1 Local Travel Costs: $0 Conference(Workshop Travel Costs: $0 Total Travel Costs: $0
Revised:7/6/2009
FORM F-3: EQUIPMENT AND CONTROLLED ASSETS Budget Category
Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur-FY 2018
Itemize,describe,and justify below. Equipment is tangible nonexpendable personal property costing $5,000 or more and a useful life
of more than one year. Approved equipment must be purchased within 90 days of contract start date.
Number of
Description of Item Purpose&Justification Units Cost Per Unit Total
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Total Amount Requested for Equipment: $0
Revised:7/6/2009
FORM F-3: EQUIPMENT AND CONTROLLED ASSETS Budget Category
Detail Form (Supplemental)
Legal Name of Respondent: [City of Port Arthur-FY 2018
Itemize,describe,and justify below. Equipment is tangible nonexpendable personal property costing$5,000 or more and a useful life
of more than one year. Approved equipment must be purchased within 90 days of contract start date.
Number of
Description of Item Purpose&Justification Units Cost Per Unit Total
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Total Amount Requested for Equipment: $0
Revised:7/6/2009
FORM F-4: SUPPLIES Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur-FY 2018
Itemize and describe each supply item and provide an estimated quantity and cost if applicable. Provide a justification for each
supply item. Costs may be categorized by each general type-office, computer, medical,educational,etc. Supplies can be
consumable-paper, drugs,etc.,OR controlled assets costing$500 or more but less than$5,000-computers, printers, phones,
medical and lab equipment,etc.
Description of Item
[If applicable.provide estimated quantity and cost(i.e.#of boxes&cost/box)] Purpose&Justification Total Cost
Total Amount Requested for Supplies: $0
Revised:7/6/2009
FORM F-4: SUPPLIES Budget Category Detail Form (Supplemental)
Legal Name of Respondent: [City of Port Arthur-FY 2018
Itemize and describe each supply item and provide an estimated quantity and cost if applicable. Provide a justification for each
supply item. Costs may be categorized by each general type-office, computer,medical,educational,etc. Supplies can be
consumable-paper,drugs,etc.,OR controlled assets costing$500 or more but less than$5,000-computers, printers, phones,
medical and lab equipment,etc.
Description of Item
[If applicable,provide estimated quantlty and cost(ie.#of boxes&cost/box)] Purpose&Justification Total Cost
Total Amount Requested for Supplies: $0
Revised:7/6/2009
FORM F-5: CONTRACTUAL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur-FY 2018
List contracts for medical services related to the scope of work that is to be provided by a third party. If a third party is not yet
identified,describe the service to be contracted and show contractors as"To Be Named." Justification for any contract that delegates
$100,000 or more of the scone of the project in the respondent's funding request,must be attached behind this form.
METHOD OF RATE OF
CONTRACTOR NAME DESCRIPTION OF SERVICES #of Months, PAYMENT
(Agency or Individual) (Scope of Work) Justification PAYMENT (i.e. Hours,Units, (i.e.hourly rate, TOTAL
Monthly,Hourly,Unit, etc. unit rate,lump
Lump Sum) sum amount)
$o
$o
$o
$o
$o
$o
So
$o
$o
$o
Total Amount Requested for CONTRACTUAL: $0
Revised:7/6/2009
FORM F-5: CONTRACTUAL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: [City of Port Arthur-FY 2018
List contracts for medical services related to the scope of work that is to be provided by a third party. If a third party is not yet
identified,describe the service to be contracted and show contractors as"To Be Named." Justification for any contract that delegates
$100,000 or more of the scooe of the project in the respondent's funding request,must be attached behind this form.
METHOD OF RATE OF
CONTRACTOR NAME DESCRIPTION OF SERVICES #of Months, PAYMENT
(Agency or Individual) (Scope of Work) Justification PAYMENT (i.e. Hours,Units, (i.e.hou ly rate, TOTAL
Monthly,Hourly,Unit, etc. unit rate,lump
Lump Sum) sum amount)
So
So
so
so
So
$o
$o
so
so
$o
Total Amount Requested for CONTRACTUAL: L $0
Revised:7/6/2009
FORM F-6: OTHER Budget Category Detail Form (Supplemental)
Legal Name of Respondent: [City of Port Arthur-FY 2018
Description of Item
[If applicable,include quantity and cost/quantity(i.e,#of units&cost/unit)] Purpose&Justification Total Cost
Total Amount Requested for Other: $0
Revised:7/6/2009
FORM F-6: OTHER Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur-FY 2018
Description of Item
[If applicable,include quantity and cost/quantity(i e z of units&cost/unit)] Purpose&Justification Total Cost
Total Amount Requested for Other: $0
Revised:7/6/2009
FORM F: BUDGET SUMMARY (REQUIRED)
Legal Name of Respondent: City of Port Arthur/FY 2019
Total Primary Health HHSC Share Patient Co-Pays
Budget Categories Care Budget Categorical Award To Be Collected
(1) (2) (3)
A. Personnel $35,640
B. Fringe Benefits $10,692
C Travel $1,332
D. Equipment $0
E. Supplies $1,636
F. Contractual $20,700
G. Other $0
H. Total Direct Costs $70.000 $0 $0
I. Indirect Costs $0
J. Total(Sum of H and I) $70,000 $0 $0
NOTE: The"Total Budget"amount for each Budget Category will have to be entered manually among columns 2 and 3. Enter amounts in whole
dollars. After amounts have been entered for each funding source,verify that the"Distribution Total"below equals the respective amount under
the"Total Budget"from column(1).
Budget Distribution Budget Budget Distribution Budget
Catetory Total Total Category Total Total
Check Totals For: Personnel $0 $35,640 Fringe Benefits $0 $10,692
Travel $0 $1,332 Equipment $0 $0
Supplies $0 $1,636 Contractual $0 $20,700
Other $0 $0 Indirect Costs $0 $0
TOTAL FOR: Distribution Totals $0 Budget Total $70,000
Revised: 11/18/2009
General Instructions for Completing Budget Forms
In preparing the budget,you must budget all costs that your organization will incur in
carrying out the Primary Health Care Program. Instructions for completing the budget
template follow:
Only respondents with cost reimbursement contracts need to
complete Forms F and F-1 through F-7.
* Enter the legal name of your organization in the space provided for"Legal
Name of Respondent"on the budget summary page. Doing so will
*
populate the budgetcategory detail templates with the organization's
zatio's
lm fete eacn o 0get categoryaetaii template. IT a n
category detail template does not accommodate all items in your budget,
use the respective supplemental budget temples at the end of this
workbook. The total of each supplemental category detail budget template
will automatically populate to the last line of the respective primary budget
category template. The definition of each category can be found in the
DSHS Contractor's Financial Procedures Manual located at the following
web site:
http://www.dshs.state.tx.us/contracts
*After you complete each budget category detail template,go to the Budget
Summary.
* Distribute the total amount in column 1 in each budget category manually
amoung the various funding sources(columns 2 and 3).
* Refer to the table below the budget template table to verify that the
amounts distributed(Distribution Total)in each budget category equals the
"Budget Total"for each respective category. Next,verify that the overall
total of all distributions(Distribution Totals)equals the Budget Total.
* Fill all budget forms out in WHOLE DOLLARS.
Revised:11/18/2009
FORM F: BUDGET SUMMARY (REQUIRED)
Legal Name of Respondent: City of Port Arthur/FY 2019
Total Primary Health HHSC Share Patient Co-Pays
Budget Categories Care Budget Categorical Award To Be Collected
(1) (2) (3)
A. Personnel $35,640
B. Fringe Benefits $10,692
C. Travel $1,332
D. Equipment $0
E. Supplies $1,636
F. Contractual $20,700
G. Other $0
H. Total Direct Costs $70,000 $0 $0
I. Indirect Costs $0
J Total(Sum of H and I) $75000 $0 $0
: The"Total Budget"amount for each Budget Category will have to be entered manually among columns 2 and 3. Enter amounts in whole
dollars. After amounts have been entered for each funding source,verify that the"Distribution Total"below equals the respective amount under
the"Total Budget"from column(1).
Budget Distribution Budget Budget Distribution Budget
Catetory Total Total Category Total Total
Check Totals For: Personnel $01 $35,64 Fringe Benefits $0 $10,6921
Travel, $0 $1,332 Equipment $0 $0
Supplies, $0 $1,636 Contractual $0 $20,700
Other $0 $0 Indirect Costs $0 $0
TOTAL FOR: 'Distribution Totals $0 Budget Total $70,000
Revised:11/18/2009
FORM F-1: PERSONNEL Budget Category Detail Form
Legal Name of Respondent: City of Port Arthur/FY 2019
PERSONNEL Certification or Total Average Number Salary/Wages
FunctionaTTitle+Code Vacant License(Enter NA if Monthly of Requested for
t=txisting or r= roposea YIN Justification FTEs not required) SalaryfWage Months Project
Medical Eligibility Billing Clerk(E) N To perform eligibility,billing and 1 No $2,970.00 12 $35,640
reporting activities
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
TOTAL FROM PERSONNEL SUPPLEMENTAL BUDGET SHEETS $0
I SalaryWage Total $35,640
FRINGE BENEFITS Iltemize the elements of fringe benefits in the space below:
FICA 7.65%Insurance 22.35%
Fringe Benefit Rate°/ 30.00% I
Fringe Benefits Total $10,692
Revised:7/6/2009
FORM F-2: TRAVEL Budget Category Detail Form
Legal Name of Respondent: City of Port Arthur/FY 2019
Conference I Workshop Travel Costs
Description of Number of:
Conference/Workshop Justification Location Travel Costs
City'State Days/Employees
Mileage
Airfare
DSHS PHC Eligibility/Training To receive updates related to Eligibility/Billing AustinfTX 1 employee 2 Meals $150
Days/1 Night Lodging $260
Other Costs $200
Total $610
Mileage
Airfare
1 employee for 2 Meals $150
DSHS PHC Eligibility Training To receive updates related to Eligibility/Billing AustinfTX Days/1 Night Lodging $260
Other Costs $200
Total $610
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
TOTAL FROM TRAVEL SUPPLEMENTAL CONFERENCE/WORKSHOP BUDGET SHEETS $0
Total for Conference I Workshop TravelIIM;I-/6/2009
Other I Local Travel Costs
Number of Mileage
Justification Miles Mileage Reimbursement Rate Cost Other Costs Total
(a) (b) (a)+01)
Travel to Local schools,health fairs,etc.
200 $0.560 $112 $112
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
TOTAL FROM TRAVEL SUPPLEMENTAL OTHER/LOCAL TRAVEL COSTS BUDGET SHEETS $0
Total for Other I Local Travel $112
Other!Local Travel Costs: $112 Conference I Workshop Travel Costs: $1,220 Total Travel Costs: [ $1,332 1
Indicate Policy Used: Respondent's Travel Policy State of Texas Travel Policy
Revised:7/6/2009
FORM F-3: EQUIPMENT AND CONTROLLED ASSETS Budget Category
Detail Form
Legal Name of Respondent: City of Port Arthur/FY 2019
Itemize, describe,and justify below. Equipment is tangible nonexpendable personal property costing $5,000 or more and a useful life
of more than one year. Approved equipment must be purchased within 90 days of contract start date.
Number of
Description of Item Purpose&Justification Units Cost Per Unit Total
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
TOTAL FROM EQUIPMENT SUPPLEMENTAL BUDGET SHEETS $0
Total Amount Requested for Equipment: $0
Revised:7/6/2009
FORM F-4: SUPPLIES Budget Category Detail Form
Legal Name of Respondent: City of Port Arthur/FY 2019
Itemize and describe each supply item and provide an estimated quantity and cost if applicable. Provide a justification for each
supply item. Costs may be categorized by each general type-office,computer,medical,educational,etc. Supplies can be
consumable-paper, drugs,etc.,OR controlled assets costing$500 or more but less than $5,000-computers, printers, phones,
medical and lab equipment,etc.
Description of Item
[If applicable,provide estimated quantity and cost(i.e#of boxes 8 cost/box)] Purpose&Justification Total Cost
Medical Supplies General medical supplies , e.g., (syringes,cotton balls,gloves,
alcohol preps,depo-medrol,drape sheet,etc $842
Office Supplies Pens, Copier paper, printer ink,folders,clip boards,etc $794
TOTAL FROM SUPPLIES SUPPLEMENTAL BUDGET SHEETS $0
Total Amount Requested for Supplies: $1,636
Revised:7/6/2009
FORM F-5: CONTRACTUAL Budget Category Detail Form
Legal Name of Respondent: City of Port Arthur/FY 2019
List contracts for medical services related to the scope of work that is to be provided by a third party. If a third party is not yet
identified,describe the service to be contracted and show contractors as"To Be Named." Justification for any contract that delegates
$100,000 or more of the sco,e of the project in the respondent's funding request,must be attached behind this form.
ME I HOU OF RATE OF
CONTRACTOR NAME DESCRIPTION OF SERVICES PAYMENT #of Months, PAYMENT
A enc or Individual) (Scope of Work) Justification (i.e.,Monthly, Hours,Units, nou ly,ate,unit TOTAL
(Agency ( P Hourly,Unit,Lump etc. rate,lump sum
Sum) amount)
Lab Corp Laboratory Services To perform lab tests outside the
scope of the city's lab Monthly 12 $1,725.00 $20,700
$0
$0
$0
$0
$0
$0
$0
$0
TOTAL FROM CONTRACTUAL SUPPLEMENTAL BUDGET SHEETS $0
Total Amount Requested for CONTRACTUAL: $20,700
Revised:7/6/2009
FORM F-6: OTHER Budget Category Detail Form
Legal Name of Respondent: City of Port Arthur/FY 2019
Description of Item
(If applicable,include quantity and cost/quantity(i.e.#of units&cost per unit)] Purpose&Justification Total Cost
TOTAL FROM OTHER SUPPLEMENTAL BUDGET SHEETS $0
Total Amount Requested for Other: $0
Revised:7/6/2009
FORM F - 7 Indirect Costs
Legal Name of Respondent: [City of Port Arthur/FY 2019
Total amount of indirect costs allocable to the project: Amount:
Indirect costs are based on(mark the statement that is applicable):
The respondent's most recent indirect cost rate approved by a federal cognizant RATE:
agency or state single audit coordinating agency. Expired rate agreements are not BASE:
acceptable. Attach a copy of the rate agreement to this form(Form I.7 Indirect)
Applies only to governmental entities.The respondent's current central service cost RATE:
rate or indirect cost rate based on a rate proposal prepared in accordance with OMB TYPE:
Circular A-87. Attach a copy of Certification of Cost Allocation Plan or BASE:
Certification of Indirect Costs.
Note:Governmental units with only a Central Service Cost Rate must also include the
indirect cost of the governmental units department(i.e.HHSC). In this case indirect
costs will be comprised of central service costs(determined by applying the rate)and
the indirect costs of the governmental department. The allocation of indirect costs must
be addressed in Part V-Indirect Cost Allocation of the Cost Allocation Plan that is
submitted to HHSC.
A cost allocation plan. A cost allocation plan as specified in the DSHS Contractor's
Financial Procedures Manual(CFPM),Appendix A must be submitted to HHSC within
60 days of the contract start date. The CFPM is available on the following intemet web
link:http://www.dshs.state.tx.us/contracts/
GO TO PAGE 2(below)
Revised:7/6/2009
Page 2, FORM F - 7 Indirect Costs
If using an central service or indirect cost rate,identify the types of costs that are included(being allocated)in the rate:
Organizations that do not use an indirect cost rate and governmental entities with only a central service rate must identify the types of costs that will be
allocated as indirect costs and the methodology used to allocate these costs in the space provided below. The costs/methodology must also be disclosed in
Part V-Indirect Cost Allocation of the Cost Allocation Plan that is submitted to DSHS. Identify the types of costs that are being allocated as indirect costs,
the allocation methodology,and the allocation base:
Revised:7/6/2009
SUPPLEMENTAL FORMS INSTRUCTIONS
The budget templates (two per budget category)that follow are intended to supplement cost reimbursement
budgets when there are too many items to fit on the primary budget template. Applicants that have utilized all
the lines on the primary budget template must use the supplemental templates to list detail information for the
respective budget category. For example, after all the lines on the primary budget template for Personnel (tab
labled Form F - 1 Personnel) have been used, go to the supplemental template labled "Form F - 1 a Personnel
Supp" and if all the lines are used on this template, go to the next template labled "Form F - lb Personnel". The
amounts on each supplemental template will automatically total and the total from both templates will
automatically be inserted on the last line of the primary budget template.
The supplemental budget templates are:
Form F-1 Personnel Supplemental
Form F-2 Travel Supplemental
Form F-3 Equipment Supplemental
Form F-4 Supplies Supplemental
Form F-5 Contractual Supplemental
Form F-6 Other Supplemental
Revised: 7/6/2009
FORM F-1: PERSONNEL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur/FY 2019
PERSONNEL Certification or Total Average Number Salary/Wages
Functional Title+Code VacantLicense(Enter NA it Monthly of Requested for
vroposea=txisting ort = YIN Justification FTE's not required) Salary/Wage Months Project
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
SalaryWage Total $0
Revised:7/6/2009
FORM F-1: PERSONNEL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur/FY 2019
PERSONNEL Certification or Total Average Number Salary!Wages
Functional Title+Code Vacant License(Enter NA if Monthly of Requested for
t=existing or t'=t roposea YIN Justification FTE's not required) SalarylWage Months Project
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
SalaryWage Total $0
Revised:7/6/2009
FORM F-2: TRAVEL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur/FY 2019
Conference I Workshop Travel Costs
Description of Location Number of:
Conference/Workshop Justification (City,State) Days/Employees Travel Costs
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Total for Conference I Workshop Travel $0
(Other f Local Travel Costs I Revised:7/6/2009
Number of Mileage
Justification Miles Mileage Reimbursement Rate Cost Other Costs Total
(a) (b) (a)*(b)
$0 $0
$0 SO
$0 $0
$0 $0
$0 SO
$0 SO
$0 $0
SO SO
$0 $0
Total for Other/Local Travel $0
Other 1 Local Travel Costs: $0 Conference/Workshop Travel Costs: $0 Total Travel Costs: $0
Revised:7/6/2009
FORM F-2: TRAVEL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: [City of Port Arthur/FY 2019
Conference/Workshop Travel Costs
Description of Location Number of:
Conference/Workshop Justification (City,State) Days/Employees Travel Costs
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Total for Conference I Workshop Travel $0
!Other/Local Travel Costs I Revised:7/6/2009
Number of Mileage
Justification Miles Mileage Reimbursement Rate Cost Other Costs Total
(a) (b) (a)+(b)
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 $0
$0 SO
$0 $0
Total for Other/Local Travel $0
Other I Local Travel Costs: $0 Conference I Workshop Travel Costs: $0 Total Travel Costs: $0
Revised:7/6/2009
FORM F-3: EQUIPMENT AND CONTROLLED ASSETS Budget Category
Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur/FY 2019
Itemize, describe,and justify below. Equipment is tangible nonexpendable personal property costing $5,000 or more and a useful life
of more than one year. Approved equipment must be purchased within 90 days of contract start date.
Number of
Description of Item Purpose&Justification Units Cost Per Unit Total
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Total Amount Requested for Equipment: $0
Revised:7/6/2009
FORM F-3: EQUIPMENT AND CONTROLLED ASSETS Budget Category
Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur/FY 2019
Itemize, describe,and justify below. Equipment is tangible nonexpendable personal property costing$5,000 or more and a useful life
of more than one year. Approved equipment must be purchased within 90 days of contract start date.
Number of
Description of Item Purpose&Justification Units Cost Per Unit Total
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Total Amount Requested for Equipment: $0
Revised:7/6/2009
FORM F-4: SUPPLIES Budget Category Detail Form (Supplemental)
Legal Name of Respondent: [City of Port Arthur/FY 2019
Itemize and describe each supply item and provide an estimated quantity and cost if applicable. Provide a justification for each
supply item. Costs may be categorized by each general type-office, computer,medical,educational,etc. Supplies can be
consumable-paper,drugs,etc.,OR controlled assets costing$500 or more but less than$5,000-computers, printers, phones,
medical and lab equipment,etc.
Description of Item
[If applicable,provide estimated quantity and cost(i.e.#of boxes&cost/box)] Purpose&Justification Total Cost
Total Amount Requested for Supplies: $0
Revised:7/6/2009
FORM F-4: SUPPLIES Budget Category Detail Form (Supplemental)
Legal Name of Respondent: [City of Port Arthur/FY 2019
Itemize and describe each supply item and provide an estimated quantity and cost if applicable. Provide a justification for each
supply item. Costs may be categorized by each general type-office, computer,medical,educational,etc. Supplies can be
consumable-paper,drugs,etc.,OR controlled assets costing$500 or more but less than$5,000-computers, printers, phones,
medical and lab equipment,etc.
Description of Item
[If applicable,provide estimated quanbty and cost(i.e.#of boxes&cost/box)] Purpose&Justification Total Cost
Total Amount Requested for Supplies: $0
Revised:7/6/2009
FORM F-5: CONTRACTUAL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur/FY 2019
List contracts for medical services related to the scope of work that is to be provided by a third party. If a third party is not yet
identified,describe the service to be contracted and show contractors as"To Be Named." Justification for any contract that delegates
$100,000 or more of the sco ae of the project in the respondent's funding request,must be attached behind this form.
METHOD OF RATE OF
CONTRACTOR NAME DESCRIPTION OF SERVICES #of Months, PAYMENT
(Agency or Individual) (Scope of Work) Justification PAYMENT (i.e. Hours,Units, (i.e.hourly rate, TOTAL
Monthly,Hourly,Unit, etc. unit rate,lump
Lump Sum) sum amount)
$0
$0
$o
$0
$0
$o
$o
$0
$0
$0
Total Amount Requested for CONTRACTUAL: $0
Revised:7/6/2009
FORM F-5: CONTRACTUAL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur/FY 2019
List contracts for medical services related to the scope of work that is to be provided by a third party. If a third party is not yet
identified,describe the service to be contracted and show contractors as "To Be Named." Justification for any contract that delegates
$100,000 or more of the scope of the project in the respondent's funding request,must be attached behind this form.
METHOD OF RATE OF
CONTRACTOR NAME DESCRIPTION OF SERVICES #of Months, PAYMENT
(Agency or Individual) (Scope of Work) Justification PAYMENT (i.e. Hours,Units, (i.e.hourly rate, TOTAL
Monthly,Hourly,Unit, etc, unit rate,lump
Lump Sum) sum amount)
$o
$o
$o
$0
$0
$0
$0
$o
$o
$o
Total Amount Requested for CONTRACTUAL: $0
Revised:7/6/2009
FORM F-6: OTHER Budget Category Detail Form (Supplemental)
Legal Name of Respondent: [City of Port Arthur/FY 2019
Description of Item
[If applicable,include quantity and cost/quantity(i.e.#of units&cost/unit)] Purpose&Justification Total Cost
Total Amount Requested for Other: $0
Revised:7/6/2009
FORM F-6: OTHER Budget Category Detail Form (Supplemental)
Legal Name of Respondent: City of Port Arthur/FY 2019
Description of Item
[It applicable include quantity and cost/quantity(i,e,#of units&cost/unit)] Purpose&Justification Total Cost
Total Amount Requested for Other: $0
Revised:7/6/2009
Attachment C — Uniform Terms and Conditions
HHSC Uniform Terms and Conditions Version 2.14
Published and Effective: March 1, 2017
Responsible Office: Chief Counsel
•'�� •••
•
* 4tir TEXAS
. ,„, •
•
. v
.:4 CC'SHealth and Human Services
•
•'• .
Health and Human Services Commission
HHSC Uniform Terms and Conditions - Grant
Version 2.14
TABLE OF CONTENTS
ARTICLE I.DEFINITIONS AND INTERPRETIVE PROVISIONS 4
1.01 Definitions 4
1.02 Interpretive Provisions 5
ARTICLE II Payment Methods and Restrictions 6
2.01 Payment Methods 6
2.02 Final Billing Submission 6
2.03 Financial Status Reports(FSRs) 7
2.04 Debt to State and Corporate Status 7
2.05 Application of Payment Due 7
2.06 Use of Funds 7
2.07 Use for Match Prohibited 7
2.08 Program Income 7
2.09 Nonsupplanting 8
ARTICLE III. STATE AND FEDERAL FUNDING 8
3.01 Funding 8
3.02 No debt Against the State 8
3.03 Debt to State 8
3.04 Recapture of Funds 8
ARTICLE IV Allowable Costs and Audit Requirements 9
4.01 Allowable Costs. 9
4.02 Independent Single or Program-Specific Audit 10
4.03 Submission of Audit 10
Article V AFFIRMATIONS,ASSURANCES AND CERTIFICATIONS 10
5.01 General Affirmations 10
5.02 Federal Assurances 10
5.03 Federal Certifications 10
ARTICLE VI OWNERSHIP AND INTELLECTUAL PROPERTY 11
6.01 Ownership 11
6.02 Intellectual Property 11
ARTICLE VII RECORDS,AUDIT,AND DISCLOSURE 11
7.01 Books and Records 11
7.02 Access to records,books, and documents 11
Grantee Uniform Terms and Conditions
Page 2 of 19
v.3.1 17
7.03 Response/compliance with audit or inspection findings 12
7.04 SAO Audit 12
7.05 Confidentiality 12
7.06 Public Information Act 12
ARTICLE VIII CONTRACT MANAGEMENT AND EARLY TERMINATION 12
8.01 Contract Management 12
8.02 Termination for Convenience 13
8.03 Termination for Cause 13
8.04 Equitable Settlement 13
ARTICLE IX MISCELLANEOUS PROVISIONS 13
9.01 Amendment 13
9.02 Insurance 13
9.03 Legal Obligations 14
9.04 Permitting and Licensure 14
9.05 Indemnity 14
9.06 Assignments 15
9.07 Relationship of the Parties 15
9.08 Technical Guidance Letters 15
9.09 Governing Law and Venue 16
9.11 Survivability 16
9.12 Force Majeure 16
9.13 No Waiver of Provisions 16
9.14 Publicity 16
9.15 Prohibition on Non-compete Restrictions 17
9.16 No Waiver of Sovereign Immunity 17
9.17 Entire Contract and Modification 17
9.18 Counterparts 17
9.19 Proper Authority 17
9.20 Employment Verification 17
9.21 Civil Rights 17
Grantee Uniform Terms and Conditions
Page 3 of 19
v.3.I.17
ARTICLE I. DEFINITIONS AND INTERPRETIVE PROVISIONS
1.01 Definitions
As used in this Contract, unless the context clearly indicates otherwise, the following terms and
conditions have the meanings assigned below:
"Amendment" means a written agreement, signed by the parties hereto, which documents
changes to the Contract other than those permitted by Work Orders or Technical Guidance
Letters, as herein defined.
"Attachment" means documents, terms, conditions, or additional information physically added
to this Contract following the Signature Document or included by reference, as if physically,
within the body of this Contract.
"Contract"means the Signature Document,these Uniform Terms and Conditions, along with any
Attachments, and any Amendments, or Technical Guidance Letters that may be issued by the
System Agency,to be incorporated by reference herein for all purposes if issued.
"Deliverable" means the work product(s) required to be submitted to the System Agency
including all reports and project documentation.
"Effective Date" means the date agreed to by the Parties as the date on which the Contract takes
effect.
"System Agency"means HHSC or any of the agencies of the State of Texas that are overseen by
HHSC under authority granted under State law and the officers, employees, and designees of
those agencies. These agencies include: the Department of Aging and Disability Services, the
Department of Family and Protective Services, and the Department of State Health Services.
"Federal Fiscal Year" means the period beginning October 1 and ending September 30 each
year,which is the annual accounting period for the United States government.
"GAAP"means Generally Accepted Accounting Principles.
"GASB"means the Governmental Accounting Standards Board.
"Grantee"means the Party receiving funds under this Contract, if any. May also be referred to as
"Contractor" in certain attachments.
"Health and Human Services Commission" or "HHSC" means the administrative agency
established under Chapter 531,Texas Government Code or its designee.
"HUB" means Historically Underutilized Business, as defined by Chapter 2161 of the Texas
Government Code.
"Intellectual Property" means inventions and business processes, whether or not patentable;
works of authorship; trade secrets; trademarks; service marks; industrial designs; and creations
Grantee Uniform Terms and Conditions
Page 4 of 19
v.3.1.17
that are subject to potential legal protection incorporated in any Deliverable and first created or
developed by Grantee, Grantee's contractor or a subcontractor in performing the Project.
"Mentor Protégé" means the Comptroller of Public Accounts' leadership program found at:
http://www.window.state.tx.us/procurement/prog/hub/mentorprotege/.
"Parties"means the System Agency and Grantee, collectively.
"Party"means either the System Agency or Grantee, individually.
"Program" means the statutorily authorized activities of the System Agency under which this
Contract has been awarded.
"Project" means specific activities of the Grantee that are supported by funds provided under this
Contract.
"Public Information Act" or"PIA"means Chapter 552 of the Texas Government Code.
"Statement of Work" means the description of activities performed in completing the Project, as
specified in the Contract and as may be amended.
"Signature Document" means the document executed by both Parties that specifically sets forth
all of the documents that constitute the Contract.
"Solicitation or "RFA" means the document issued by the System Agency under which
applications for Program funds were requested, which is incorporated herein by reference for all
purposes in its entirety, including all Amendments and Attachments.
"Solicitation Response" or "Application" means Grantee's full and complete response to the
Solicitation, which is incorporated herein by reference for all purposes in its entirety, including
any Attachments and addenda.
"State Fiscal Year" means the period beginning September 1 and ending August 31 each year,
which is the annual accounting period for the State of Texas.
"State of Texas Textravel" means Texas Administrative Code, Title 34, Part 1, Chapter 5,
Subchapter C, Section 5.22,relative to travel reimbursements under this Contract, if any.
"Technical Guidance Letter" or "TGL" means an instruction, clarification, or interpretation of
the requirements of the Contract,issued by the System Agency to the Grantee.
1.02 Interpretive Provisions
a. The meanings of defined terms are equally applicable to the singular and plural forms of the
defined terms.
b. The words "hereof," "herein," "hereunder," and similar words refer to this Contract as a
whole and not to any particular provision, section, Attachment, or schedule of this Contract
unless otherwise specified.
c. The term "including" is not limiting and means "including without limitation" and, unless
otherwise expressly provided in this Contract, (i) references to contracts (including this
Contract) and other contractual instruments shall be deemed to include all subsequent
Grantee Uniform Terms and Conditions
Page 5 of 19
v.3.1.17
Amendments and other modifications thereto, but only to the extent that such Amendments
and other modifications are not prohibited by the terms of this Contract, and(ii) references to
any statute or regulation are to be construed as including all statutory and regulatory
provisions consolidating, amending, replacing, supplementing, or interpreting the statute or
regulation.
d. Any references to "sections," "appendices," or "attachments" are references to sections,
appendices, or attachments of the Contract.
e. Any references to agreements, contracts, statutes, or administrative rules or regulations in the
Contract are references to these documents as amended, modified, or supplemented from
time to time during the term of the Contract.
f. The captions and headings of this Contract are for convenience of reference only and do not
affect the interpretation of this Contract.
g. All Attachments within this Contract, including those incorporated by reference, and any
Amendments are considered part of the terms of this Contract.
h. This Contract may use several different limitations, regulations, or policies to regulate the
same or similar matters. All such limitations, regulations, and policies are cumulative and
each will be performed in accordance with its terms.
i. Unless otherwise expressly provided, reference to any action of the System Agency or by the
System Agency by way of consent, approval, or waiver will be deemed modified by the
phrase "in its sole discretion."
j. Time is of the essence in this Contract.
ARTICLE II PAYMENT METHODS AND RESTRICTIONS
2.01 Payment Methods
Except as otherwise provided by the provisions of the Contract, the payment method will be one
or more of the following:
a. cost reimbursement. This payment method is based on an approved budget and submission
of a request for reimbursement of expenses Grantee has incurred at the time of the request;
b. unit rate/fee-for-service. This payment method is based on a fixed price or a specified rate(s)
or fee(s) for delivery of a specified unit(s) of service and acceptable submission of all
required documentation, forms and/or reports; or
c. advance payment. This payment method is based on disbursal of the minimum necessary
funds to carry out the Program or Project where the Grantee has implemented appropriate
safeguards. This payment method will only be utilized in accordance with governing law
and at the sole discretion of the System Agency.
Grantees shall bill the System Agency in accordance with the Contract. Unless otherwise
specified in the Contract, Grantee shall submit requests for reimbursement or payment monthly
by the last business day of the month following the month in which expenses were incurred or
services provided. Grantee shall maintain all documentation that substantiates invoices and make
the documentation available to the System Agency upon request.
2.02 Final Billing Submission
Unless otherwise provided by the System Agency, Grantee shall submit a reimbursement or
payment request as a fmal close-out invoice not later than forty-five(45)calendar days following
Grantee Uniform Terms and Conditions
Page 6 of 19
v.3.1.17
the end of the term of the Contract. Reimbursement or payment requests received in the System
Agency's offices more than forty-five (45) calendar days following the termination of the
Contract may not be paid.
2.03 Financial Status Reports (FSRs)
Except as otherwise provided in these General Provisions or in the terms of any Program
Attachment(s) that is incorporated into the Contract, for contracts with categorical budgets,
Grantee shall submit quarterly FSRs to Accounts Payable by the last business day of the month
following the end of each quarter of the Program Attachment term for System Agency review
and financial assessment. Grantee shall submit the final FSR no later than forty-five (45)
calendar days following the end of the applicable term.
2.04 Debt to State and Corporate Status
Pursuant to Tex. Gov. Code § 403.055, the Department will not approve and the State
Comptroller will not issue payment to Grantee if Grantee is indebted to the State for any reason,
including a tax delinquency. Grantee, if a corporation, certifies by execution of this Contract that
it is current and will remain current in its payment of franchise taxes to the State of Texas or that
it is exempt from payment of franchise taxes under Texas law (Tex. Tax Code §§ 171.001 et
seq.). If tax payments become delinquent during the Contract term, all or part of the payments
under this Contract may be withheld until Grantee's delinquent tax is paid in full.
2.05 Application of Payment Due
Grantee agrees that any payments due under this Contract will be applied towards any debt of
Grantee, including but not limited to delinquent taxes and child support that is owed to the State
of Texas.
2.06 Use of Funds
Grantee shall expend funds provided under this Contract only for the provision of approved
services and for reasonable and allowable expenses directly related to those services.
2.07 Use for Match Prohibited
Grantee shall not use funds provided under this Contract for matching purposes in securing other
funding without the written approval of the System Agency.
2.08 Program Income
Income directly generated from funds provided under this Contract or earned only as a result of
such funds is Program Income. Unless otherwise required under the Program, Grantee shall use
the addition alternative, as provided in UGMS § _.25(g)(2), for the use of Project income to
further the Program, and Grantee shall spend the Program Income on the Project. Grantee shall
identify and report this income in accordance with the Contract, applicable law, and any
programmatic guidance. Grantee shall expend Program Income during the Contract term and
may not carry Program Income forward to any succeeding term. Grantee shall refund program
income to the System Agency if the Program Income is not expended in the term in which it is
earned. The System Agency may base future funding levels, in part, upon Grantee's proficiency
in identifying, billing, collecting, and reporting Program Income, and in using it for the purposes
and under the conditions specified in this Contract.
Grantee Uniform Terms and Conditions
Page 7 of 19
v.3.1.17
2.09 Nonsupplanting
Grantee shall not use funds from this Contract to replace or substitute for existing funding from
other but shall use funds from this Contract to supplement existing state or local funds currently
available. Grantee shall make a good faith effort to maintain its current level of support.
Grantee may be required to submit documentation substantiating that a reduction in state or local
funding, if any, resulted for reasons other than receipt or expected receipt of funding under this
Contract.
ARTICLE III. STATE AND FEDERAL FUNDING
3.01 Funding
This Contract is contingent upon the availability of sufficient and adequate funds. If funds
become unavailable through lack of appropriations, budget cuts, transfer of funds between
programs or agencies, amendment of the Texas General Appropriations Act, agency
consolidation, or any other disruptions of current funding for this Contract, the System Agency
may restrict, reduce, or terminate funding under this Contract. This Contract is also subject to
immediate cancellation or termination, without penalty to the System Agency, if sufficient and
adequate funds are not available. Grantee will have no right of action against the System Agency
if the System Agency cannot perform its obligations under this Contract as a result of lack of
funding for any activities or functions contained within the scope of this Contract. In the event of
cancellation or termination under this Section, the System Agency will not be required to give
notice and will not be liable for any damages or losses caused or associated with such
termination or cancellation.
3.02 No debt Against the State
The Contract will not be construed as creating any debt by or on behalf of the State of Texas.
3.03 Debt to State
If a payment law prohibits the Texas Comptroller of Public Accounts from making a payment,
the Grantee acknowledges the System Agency's payments under the Contract will be applied
toward eliminating the debt or delinquency. This requirement specifically applies to any debt or
delinquency, regardless of when it arises.
3.04 Recapture of Funds
The System Agency may withhold all or part of any payments to Grantee to offset overpayments
made to the Grantee. Overpayments as used in this Section include payments (i) made by the
System Agency that exceed the maximum allowable rates; (ii)that are not allowed under applicable
laws, rules, or regulations; or(iii) that are otherwise inconsistent with this Contract, including any
unapproved expenditures. Grantee understands and agrees that it will be liable to the System
Agency for any costs disallowed pursuant to financial and compliance audit(s) of funds received
under this Contract. Grantee further understands and agrees that reimbursement of such
disallowed costs will be paid by Grantee from funds which were not provided or otherwise made
available to Grantee under this Contract.
Grantee Uniform Terms and Conditions
Page 8 of 19
v.3.1.17
ARTICLE IV ALLOWABLE COSTS AND AUDIT REQUIREMENTS
4.01 Allowable Costs.
System Agency will reimburse the allowable costs incurred in performing the Project that are
sufficiently documented. Grantee must have incurred a cost prior to claiming reimbursement and
within the applicable term to be eligible for reimbursement under this Contract. The System
Agency will determine whether costs submitted by Grantee are allowable and eligible for
reimbursement. If the System Agency has paid funds to Grantee for unallowable or ineligible
costs, the System Agency will notify Grantee in writing, and Grantee shall return the funds to the
System Agency within thirty (30) calendar days of the date of this written notice. The System
Agency may withhold all or part of any payments to Grantee to offset reimbursement for any
unallowable or ineligible expenditure that Grantee has not refunded to the System Agency, or if
financial status report(s)required under the Financial Status Reports section are not submitted by
the due date(s). The System Agency may take repayment (recoup) from funds available under
this Contract in amounts necessary to fulfill Grantee's repayment obligations. Applicable cost
principles, audit requirements, and administrative requirements include-
Applicable Entity Applicable Cost Audit Administrative
Principles Requirements Requirements
State, Local and 2 CFR, Part 225 2 CFR Part 200, 2 CFR Part 200 and
Tribal Governments Subpart F and UGMS
UGMS
Educational 2 CFR, Part 220 2 CFR Part 200, 2 CFR Part 200 and
Institutions Subpart F and UGMS
UGMS
Non-Profit 2 CFR, Part 230 2 CFR Part 200, 2 CFR Part 200 and
Organizations Subpart F and UGMS
UGMS
For-profit 48 CFR Part 31, 2 CFR Part 200, 2 CFR Part 200 and
Organization other Contract Cost Subpart F and UGMS
than a hospital and an Principles UGMS
organization named in Procedures, or
OMB Circular A-122 uniform cost
(2 CFR Part, 230) as accounting
not subject to that standards that
circular. comply with cost
principles
acceptable to the
federal or state
awarding agency
Grantee Uniform Terms and Conditions
Page 9 of 19
v.3.1.17
OMB Circulars will be applied with the modifications prescribed by UGMS with effect given to
whichever provision imposes the more stringent requirement in the event of a conflict.
4.02 Independent Single or Program-Specific Audit
If Grantee,within Grantee's fiscal year, expends a total amount of at least SEVEN HUNDRED
FIFTY THOUSAND DOLLARS ($750,000) in federal funds awarded,Grantee shall have a
single audit or program-specific audit in accordance with 2 CFR 200. The $750,000 federal
threshold amount includes federal funds passed through by way of state agency awards. If
Grantee,within Grantee's fiscal year, expends a total amount of at least$750,000 in state funds
awarded, Grantee must have a single audit or program-specific audit in accordance with UGMS,
State of Texas Single Audit Circular. The audit must be conducted by an independent certified
public accountant and in accordance with 2 CFR 200, Government Auditing Standards, and
UGMS. For-profit Grantees whose expenditures meet or exceed the federal or state expenditure
thresholds stated above shall follow the guidelines in 2 CFR 200 or UGMS, as applicable, for
their program-specific audits. HHSC Single Audit Services will notify Grantee to complete the
Single Audit Determination Form. If Grantee fails to complete the Single Audit Determination
Form within thirty(30)calendar days after notification by HHSC Single Audit Services to do so,
Grantee shall be subject to the System Agency sanctions and remedies for non-compliance with
this Contract. Each Grantee that is required to obtain a single audit must competitively re-
procure single audit services once every six years. Grantee shall procure audit services in
compliance with this section, state procurement procedures, as well as with the provisions of
UGMS.
4.03 Submission of Audit
Due the earlier of 30 days after receipt of the independent certified public accountant's report or
nine months after the end of the fiscal year, Grantee shall submit electronically, one copy of the
Single Audit or Program-Specific Audit to the System Agency as directed in this Contract and
another copy to: single_audit_report@hhsc.state.tx.us
ARTICLE V AFFIRMATIONS,ASSURANCES AND CERTIFICATIONS
5.01 General Affirmations
Grantee certifies that, to the extent General Affirmations are incorporated into the Contract under
the Signature Document, the General Affirmations have been reviewed and that Grantee is in
compliance with each of the requirements reflected therein.
5.02 Federal Assurances
Grantee further certifies that, to the extent Federal Assurances are incorporated into the Contract
under the Signature Document, the Federal Assurances have been reviewed and that Grantee is
in compliance with each of the requirements reflected therein.
5.03 Federal Certifications
Grantee further certifies, to the extent Federal Certifications are incorporated into the Contract
under the Signature Document, that the Federal Certifications have been reviewed, and that
Grantee is in compliance with each of the requirements reflected therein. In addition, Grantee
certifies that it is in compliance with all applicable federal laws, rules, or regulations, as they
may pertain to this Contract.
Grantee Uniform Terms and Conditions
Page 10 of 19
v.3.1.17
ARTICLE VI OWNERSHIP AND INTELLECTUAL PROPERTY
6.01 Ownership
The System Agency will own, and Grantee hereby assigns to the System Agency, all right, title,
and interest in all Deliverables.
6.02 Intellectual Property
a. The System Agency and Grantee will retain ownership, all rights, title, and interest in and to,
their respective pre-existing Intellectual Property. A license to either Party's pre-existing
Intellectual Property must be agreed to under this or another contract.
b. Grantee grants to the System Agency and the State of Texas a royalty-free, paid up,
worldwide,perpetual, non-exclusive,non-transferable license to use any Intellectual Property
invented or created by Grantee,Grantee's contractor, or a subcontractor in the performance of
the Project. Grantee will require its contractors to grant such a license under its contracts.
ARTICLE VII RECORDS, AUDIT, AND DISCLOSURE
7.01 Books and Records
Grantee will keep and maintain under GAAP or GASB, as applicable, full, true, and complete
records necessary to fully disclose to the System Agency, the Texas State Auditor's Office, the
United States Government, and their authorized representatives sufficient information to
determine compliance with the terms and conditions of this Contract and all state and federal
rules, regulations, and statutes. Unless otherwise specified in this Contract, Grantee will
maintain legible copies of this Contract and all related documents for a minimum of seven (7)
years after the termination of the contract period or seven (7) years after the completion of any
litigation or dispute involving the Contract,whichever is later.
7.02 Access to records,books, and documents
In addition to any right of access arising by operation of law, Grantee and any of Grantee's
affiliate or subsidiary organizations, or Subcontractors will permit the System Agency or any of
its duly authorized representatives, as well as duly authorized federal, state or local authorities,
unrestricted access to and the right to examine any site where business is conducted or Services
are performed, and all records, which includes but is not limited to fmancial, client and patient
records, books, papers or documents related to this Contract. If the Contract includes federal
funds, federal agencies that will have a right of access to records as described in this section
include: the federal agency providing the funds, the Comptroller General of the United States,
the General Accounting Office, the Office of the Inspector General, and any of their authorized
representatives. In addition, agencies of the State of Texas that will have a right of access to
records as described in this section include: the System Agency, HHSC, HHSC's contracted
examiners, the State Auditor's Office, the Texas Attorney General's Office, and any successor
agencies. Each of these entities may be a duly authorized authority. If deemed necessary by the
System Agency or any duly authorized authority, for the purpose of investigation or hearing,
Grantee will produce original documents related to this Contract. The System Agency and any
duly authorized authority will have the right to audit billings both before and after payment, and
all documentation that substantiates the billings. Grantee will include this provision concerning
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the right of access to, and examination of, sites and information related to this Contract in any
Subcontract it awards.
7.03 Response/compliance with audit or inspection findings
a. Grantee must act to ensure its and its Subcontractor's compliance with all corrections
necessary to address any finding of noncompliance with any law, regulation, audit
requirement, or generally accepted accounting principle, or any other deficiency identified in
any audit, review, or inspection of the Contract and the goods or services provided
hereunder. Any such correction will be at Grantee or its Subcontractor's sole expense.
Whether Grantee's action corrects the noncompliance will be solely the decision of the
System Agency.
b. As part of the Services, Grantee must provide to HHSC upon request a copy of those portions
of Grantee's and its Subcontractors' internal audit reports relating to the Services and
Deliverables provided to the State under the Contract.
7.04 SAO Audit
Grantee understands that acceptance of funds directly under the Contract or indirectly through a
Subcontract under the Contract acts as acceptance of the authority of the State Auditor's Office
(SAO), or any successor agency, to conduct an audit or investigation in connection with those
funds. Under the direction of the legislative audit committee, an entity that is the subject of an
audit or investigation by the SAO must provide the SAO with access to any information the SAO
considers relevant to the investigation or audit. Grantee agrees to cooperate fully with the SAO
or its successor in the conduct of the audit or investigation, including providing all records
requested. Grantee will ensure that this clause concerning the authority to audit funds received
indirectly by Subcontractors through Grantee and the requirement to cooperate is included in any
Subcontract it awards.
7.05 Confidentiality
Any specific confidentiality agreement between the Parties takes precedent over the terms of this
section. To the extent permitted by law, Grantee agrees to keep all information confidential, in
whatever form produced, prepared, observed, or received by Grantee. The provisions of this
section remain in full force and effect following termination or cessation of the services
performed under this Contract.
7.06 Public Information Act
Information related to the performance of this Contract may be subject to the PIA and will be
withheld from public disclosure or released only in accordance therewith. Grantee must make all
information not otherwise excepted from disclosure under the PIA available in portable
document file(".pdf') format or any other format agreed between the Parties.
ARTICLE VIII CONTRACT MANAGEMENT AND EARLY TERMINATION
8.01 Contract Management
To ensure full performance of the Contract and compliance with applicable law, the System
Agency may take actions including:
a. Suspending all or part of the Contract;
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b. Requiring the Grantee to take specific corrective actions in order to remain in compliance
with term of the Contract;
c. Recouping payments made to the Grantee found to be in error;
d. Suspending, limiting, or placing conditions on the continued performance of the Project;
e. Imposing any other remedies authorized under this Contract; and
f. Imposing any other remedies, sanctions or penalties permitted by federal or state statute, law,
regulation,or rule.
8.02 Termination for Convenience
The System Agency may terminate the Contract at any time when, in its sole discretion, the
System Agency determines that termination is in the best interests of the State of Texas. The
termination will be effective on the date specified in HHSC's notice of termination.
8.03 Termination for Cause
Except as otherwise provided by the U.S. Bankruptcy Code, or any successor law, the System
Agency may terminate the Contract, in whole or in part, upon either of the following conditions:
a. Material Breach
The System Agency will have the right to terminate the Contract in whole or in part if the
System Agency determines, at its sole discretion, that Grantee has materially breached the
Contract or has failed to adhere to any laws, ordinances, rules, regulations or orders of any public
authority having jurisdiction and such violation prevents or substantially impairs performance of
Grantee's duties under the Contract. Grantee's misrepresentation in any aspect of Grantee's
Solicitation Response, if any or Grantee's addition to the Excluded Parties List System (EPLS)
will also constitute a material breach of the Contract.
b. Failure to Maintain Financial Viability
The System Agency may terminate the Contract if, in its sole discretion, the System Agency has
a good faith belief that Grantee no longer maintains the financial viability required to complete
the Services and Deliverables, or otherwise fully perform its responsibilities under the Contract.
8.04 Equitable Settlement
Any early termination under this Article will be subject to the equitable settlement of the
respective interests of the Parties up to the date of termination.
ARTICLE IX MISCELLANEOUS PROVISIONS
9.01 Amendment
The Contract may only be amended by an Amendment executed by both Parties.
9.02 Insurance
Unless otherwise specified in this Contract, Grantee will acquire and maintain, for the duration of
this Contract, insurance coverage necessary to ensure proper fulfillment of this Contract and
potential liabilities thereunder with financially sound and reputable insurers licensed by the
Texas Department of Insurance, in the type and amount customarily carried within the industry
as determined by the System Agency. Grantee will provide evidence of insurance as required
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under this Contract, including a schedule of coverage or underwriter's schedules establishing to
the satisfaction of the System Agency the nature and extent of coverage granted by each such
policy, upon request by the System Agency. In the event that any policy is determined by the
System Agency to be deficient to comply with the terms of this Contract, Grantee will secure
such additional policies or coverage as the System Agency may reasonably request or that are
required by law or regulation. If coverage expires during the term of this Contract, Grantee must
produce renewal certificates for each type of coverage.
These and all other insurance requirements under the Contract apply to both Grantee and its
Subcontractors, if any. Grantee is responsible for ensuring its Subcontractors' compliance with all
requirements.
9.03 Legal Obligations
Grantee will comply with all applicable federal, state, and local laws, ordinances, and
regulations, including all federal and state accessibility laws relating to direct and indirect use of
information and communication technology. Grantee will be deemed to have knowledge of all
applicable laws and regulations and be deemed to understand them. In addition to any other act
or omission that may constitute a material breach of the Contract, failure to comply with this
Section may also be a material breach of the Contract.
9.04 Permitting and Licensure
At Grantee's sole expense, Grantee will procure and maintain for the duration of this Contract
any state, county, city, or federal license, authorization, insurance, waiver, permit, qualification
or certification required by statute, ordinance, law, or regulation to be held by Grantee to provide
the goods or Services required by this Contract. Grantee will be responsible for payment of all
taxes, assessments, fees, premiums, permits, and licenses required by law. Grantee agrees to be
responsible for payment of any such government obligations not paid by its contactors or
subcontractors during performance of this Contract.
9.05 Indemnity
To THE EXTENT ALLOWED BY LAW, GRANTEE WILL DEFEND, INDEMNIFY, AND HOLD
HARMLESS THE STATE OF TEXAS AND ITS OFFICERS AND EMPLOYEES, AND THE SYSTEM
AGENCY AND ITS OFFICERS AND EMPLOYEES, FROM AND AGAINST ALL CLAIMS, ACTIONS,
SUITS, DEMANDS, PROCEEDINGS, COSTS, DAMAGES, AND LIABILITIES, INCLUDING ATTORNEYS'
FEES AND COURT COSTS ARISING OUT OF,OR CONNECTED WITH,OR RESULTING FROM:
a. GRANTEE'S PERFORMANCE OF THE CONTRACT, INCLUDING ANY NEGLIGENT ACTS OR
OMISSIONS OF GRANTEE, OR ANY AGENT, EMPLOYEE, SUBCONTRACTOR, OR SUPPLIER OF
GRANTEE, OR ANY THIRD PARTY UNDER THE CONTROL OR SUPERVISION OF GRANTEE, IN
THE EXECUTION OR PERFORMANCE OF THIS CONTRACT;OR
b. ANY BREACH OR VIOLATION OF A STATUTE, ORDINANCE, GOVERNMENTAL REGULATION,
STANDARD, RULE, OR BREACH OF CONTRACT BY GRANTEE, ANY AGENT, EMPLOYEE,
SUBCONTRACTOR,OR SUPPLIER OF GRANTEE,OR ANY THIRD PARTY UNDER THE CONTROL
OR SUPERVISION OF GRANTEE,IN THE EXECUTION OR PERFORMANCE OF THIS CONTRACT;
OR
C. EMPLOYMENT OR ALLEGED EMPLOYMENT, INCLUDING CLAIMS OF DISCRIMINATION
AGAINST GRANTEE,ITS OFFICERS,OR ITS AGENTS;OR
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d. WORK UNDER THIS CONTRACT THAT INFRINGES OR MISAPPROPRIATES ANY RIGHT OF ANY
THIRD PERSON OR ENTITY BASED ON COPYRIGHT, PATENT, TRADE SECRET, OR OTHER
INTELLECTUAL PROPERTY RIGHTS.
GRANTEE WILL COORDINATE ITS DEFENSE WITH THE SYSTEM AGENCY AND ITS COUNSEL.
THIS PARAGRAPH IS NOT INTENDED TO AND WILL NOT BE CONSTRUED TO REQUIRE GRANTEE
TO INDEMNIFY OR HOLD HARMLESS THE STATE OR THE SYSTEM AGENCY FOR ANY CLAIMS OR
LIABILITIES RESULTING SOLELY FROM THE GROSS NEGLIGENCE OF THE SYSTEM AGENCY OR
ITS EMPLOYEES. THE PROVISIONS OF THIS SECTION WILL SURVIVE TERMINATION OF THIS
CONTRACT.
9.06 Assignments
Grantee may not assign all or any portion of its rights under, interests in, or duties required under
this Contract without prior written consent of the System Agency, which may be withheld or
granted at the sole discretion of the System Agency. Except where otherwise agreed in writing
by the System Agency, assignment will not release Grantee from its obligations under the
Contract.
Grantee understands and agrees the System Agency may in one or more transactions assign,
pledge, or transfer the Contract. This assignment will only be made to another State agency or a
non-state agency that is contracted to perform agency support.
9.07 Relationship of the Parties
Grantee is, and will be, an independent contractor and, subject only to the terms of this Contract,
will have the sole right to supervise, manage, operate, control, and direct performance of the
details incident to its duties under this Contract. Nothing contained in this Contract will be
deemed or construed to create a partnership or joint venture, to create relationships of an
employer-employee or principal-agent, or to otherwise create for the System Agency any
liability whatsoever with respect to the indebtedness, liabilities, and obligations of Grantee or
any other Party.
Grantee will be solely responsible for, and the System Agency will have no obligation with
respect to:
a. Payment of Grantee's employees for all Services performed;
b. Ensuring each of its employees, agents, or Subcontractors who provide Services or
Deliverables under the Contract are properly licensed, certified, or have proper permits to
perform any activity related to the Work;
c. Withholding of income taxes,FICA,or any other taxes or fees;
d. Industrial or workers' compensation insurance coverage;
e. Participation in any group insurance plans available to employees of the State of Texas;
f. Participation or contributions by the State to the State Employees Retirement System;
g. Accumulation of vacation leave or sick leave; or
h. Unemployment compensation coverage provided by the State.
9.08 Technical Guidance Letters
In the sole discretion of the System Agency, and in conformance with federal and state law, the
System Agency may issue instructions, clarifications, or interpretations as may be required
during Work performance in the form of a Technical Guidance Letter. A TGL must be in
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writing, and may be delivered by regular mail, electronic mail, or facsimile transmission. Any
TGL issued by the System Agency will be incorporated into the Contract by reference herein for
all purposes when it is issued.
9.09 Governing Law and Venue
This Contract and the rights and obligations of the Parties hereto will be governed by, and
construed according to, the laws of the State of Texas, exclusive of conflicts of law provisions.
Venue of any suit brought under this Contract will be in a court of competent jurisdiction in
Travis County, Texas unless otherwise elected by the System Agency. Grantee irrevocably
waives any objection, including any objection to personal jurisdiction or the laying of venue or
based on the grounds of forum non conveniens, which it may now or hereafter have to the
bringing of any action or proceeding in such jurisdiction in respect of this Contract or any
document related hereto.
9.10 Severability
If any provision contained in this Contract is held to be unenforceable by a court of law or
equity, this Contract will be construed as if such provision did not exist and the non-
enforceability of such provision will not be held to render any other provision or provisions of
this Contract unenforceable.
9.11 Survivability
Termination or expiration of this Contract or a Contract for any reason will not release either
party from any liabilities or obligations in this Contract that the parties have expressly agreed
will survive any such termination or expiration, remain to be performed, or by their nature would
be intended to be applicable following any such termination or expiration, including maintaining
confidentiality of information and records retention.
9.12 Force Majeure
Except with respect to the obligation of payments under this Contract, if either of the Parties,
after a good faith effort, is prevented from complying with any express or implied covenant of
this Contract by reason of war; terrorism; rebellion; riots; strikes; acts of God; any valid order,
rule, or regulation of governmental authority; or similar events that are beyond the control of the
affected Party (collectively referred to as a "Force Majeure"), then, while so prevented, the
affected Party's obligation to comply with such covenant will be suspended, and the affected
Party will not be liable for damages for failure to comply with such covenant. In any such event,
the Party claiming Force Majeure will promptly notify the other Party of the Force Majeure
event in writing and, if possible, such notice will set forth the extent and duration thereof.
9.13 No Waiver of Provisions
Neither failure to enforce any provision of this Contract nor payment for services provided under
it constitute waiver of any provision of the Contract.
9.14 Publicity
Except as provided in the paragraph below, Grantee must not use the name of, or directly or
indirectly refer to, the System Agency, the State of Texas, or any other State agency in any
media release, public announcement, or public disclosure relating to the Contract or its subject
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matter, including in any promotional or marketing materials, customer lists, or business
presentations.
Grantee may publish, at its sole expense, results of Grantee performance under the Contract with
the System Agency's prior review and approval, which the System Agency may exercise at its
sole discretion. Any publication (written, visual, or sound) will acknowledge the support
received from the System Agency and any Federal agency, as appropriate.
9.15 Prohibition on Non-compete Restrictions
Grantee will not require any employees or Subcontractors to agree to any conditions, such as
non-compete clauses or other contractual arrangements that would limit or restrict such persons
or entities from employment or contracting with the State of Texas.
9.16 No Waiver of Sovereign Immunity
Nothing in the Contract will be construed as a waiver of sovereign immunity by the System
Agency.
9.17 Entire Contract and Modification
The Contract constitutes the entire agreement of the Parties and is intended as a complete and
exclusive statement of the promises, representations, negotiations, discussions, and other
agreements that may have been made in connection with the subject matter hereof. Any
additional or conflicting terms in any future document incorporated into the Contract will be
harmonized with this Contract to the extent possible by the System Agency.
9.18 Counterparts
This Contract may be executed in any number of counterparts, each of which will be an original,
and all such counterparts will together constitute but one and the same Contract.
9.19 Proper Authority
Each Party hereto represents and warrants that the person executing this Contract on its behalf
has full power and authority to enter into this Contract. Any Services or Work performed by
Grantee before this Contract is effective or after it ceases to be effective are performed at the sole
risk of Grantee with respect to compensation.
9.20 Employment Verification
Grantee will confirm the eligibility of all persons employed during the contract term to perform
duties within Texas and all persons, including subcontractors, assigned by the contractor to
perform work pursuant to the Contract.
9.21 Civil Rights
a. Grantee agrees to comply with state and federal anti-discrimination laws, including:
1. Title VI of the Civil Rights Act of 1964(42 U.S.C. §2000d et seq.);
2. Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794);
3. Americans with Disabilities Act of 1990(42 U.S.C. §12101 et seq.);
4. Age Discrimination Act of 1975 (42 U.S.C. §§6101-6107);
5. Title IX of the Education Amendments of 1972 (20 U.S.C. §§1681-1688);
6. Food and Nutrition Act of 2008 (7 U.S.C. §2011 et seq.); and
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7. The System Agency's administrative rules, as set forth in the Texas Administrative Code,
to the extent applicable to this Agreement.
Grantee agrees to comply with all amendments to the above-referenced laws, and all
requirements imposed by the regulations issued pursuant to these laws. These laws provide in
part that no persons in the United States may, on the grounds of race, color, national origin,
sex, age, disability, political beliefs, or religion, be excluded from participation in or denied
any aid, care, service or other benefits provided by Federal or State funding, or otherwise be
subjected to discrimination.
b. Grantee agrees to comply with Title VI of the Civil Rights Act of 1964, and its implementing
regulations at 45 C.F.R. Part 80 or 7 C.F.R. Part 15, prohibiting a contractor from adopting
and implementing policies and procedures that exclude or have the effect of excluding or
limiting the participation of clients in its programs, benefits, or activities on the basis of
national origin. State and federal civil rights laws require contractors to provide alternative
methods for ensuring access to services for applicants and recipients who cannot express
themselves fluently in English. Grantee agrees to take reasonable steps to provide services
and information, both orally and in writing, in appropriate languages other than English, in
order to ensure that persons with limited English proficiency are effectively informed and
can have meaningful access to programs,benefits, and activities.
c. Grantee agrees to post applicable civil rights posters in areas open to the public informing
clients of their civil rights and including contact information for the HHS Civil Rights Office.
The posters are available on the HHS website at: http://hhscx.hhsc.texas.gov/system-support-
services/civil-rights/publications
d. Grantee agrees to comply with Executive Order 13279, and its implementing regulations at
45 C.F.R. Part 87 or 7 C.F.R. Part 16. These provide in part that any organization that
participates in programs funded by direct financial assistance from the United States
Department of Agriculture or the United States Department of Health and Human Services
shall not discriminate against a program beneficiary or prospective program beneficiary on
the basis of religion or religious belief.
e. Upon request, Grantee will provide HHSC Civil Rights Office with copies of all of the
Grantee's civil rights policies and procedures.
f. Grantee must notify HHSC's Civil Rights Office of any civil rights complaints received
relating to its performance under this Agreement. This notice must be delivered no more than
ten (10) calendar days after receipt of a complaint. Notice provided pursuant to this section
must be directed to:
HHSC Civil Rights Office
701 W. 51St Street, Mail Code W206
Austin,Texas 78751
Phone Toll Free: (888) 388-6332
Phone: (512)438-4313
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TTY Toll Free: (877)432-7232
Fax: (512)438-5885.
Grantee Uniform Terms and Conditions
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Attachment D — Special Conditions
•
•
: v v • TEXAS
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•.
Health and Human Services Commission
Special Conditions
Version 1.0
TABLE OF CONTENTS
ARTICLE I. Special Definitions 1
ARTICLE II. Grantees Personnel 2
2.01 Qualifications 2
2.02 Conduct and Removal 2
ARTICLE III. Confidentiality 2
3.01 Confidential System Information 2
ARTICLE IV. Miscellaneous Provisions 3
4.01 Conflicts of Interest 3
4.02 Flow Down Provisions 3
ARTICLE V.DSHS Legacy Provisions 4
5.01 Notice of Criminal Activity and Disciplinary Actions 4
5.02 Notice of IRS or TWC Insolvency 4
5.03 Disaster Services 4
5.04 Consent by Non-Parent or Other State Law to Medical Care of a Minor 4
5.05 Services and Information for Persons with Limited English Proficiency 5
5.06 Third Party Payors 5
5.07 HIV/AIDS Model Workplace Guidelines 5
5.8 Medical Records Retention 6
5.9 Notice of a License Action 6
5.10 Interim Extension Amendment 6
5.11 Child Abuse Reporting Requirement 6
5.12 Grantee's Certification of Meeting or Exceeding Tobacco-Free Workplace Policy
Minimum Standards 7
HHSC SPECIAL CONDITIONS
The terms and conditions of these Special Conditions are incorporated into and made a part of the Contract.
Capitalized items used in these Special Conditions and not otherwise defined have the meanings assigned
to them in HHSC Grantee Uniform Terms and Conditions—Version 2.14
Article I. SPECIAL DEFINITIONS
"Conflict of Interest"means a set of facts or circumstances,a relationship,or other situation under which
Grantee,a Subcontractor,or individual has past,present,or currently planned personal or financial activities
or interests that either directly or indirectly: (1) impairs or diminishes the Grantee's, or Subcontractor's
ability to render impartial or objective assistance or advice to the HHSC; or(2) provides the Grantee or
Subcontractor an unfair competitive advantage in future HHSC procurements.
"Grantee Agents" means Grantee's representatives, employees, officers, as well as any contractor or
subgrantee's employees,contractors,officers,principals and agents.
"Data Use Agreement"means the agreement incorporated into the Contract to facilitate creation,receipt,
maintenance,use,disclosure or access to Confidential Information.
"Item of Noncompliance"means Grantee's acts or omissions that: (1)violate a provision of the Contract;
(2)fail to ensure adequate performance of the Project;(3)represent a failure of Grantee to be responsive to
a request of HHSC relating to the Project under the Contract.
"Minor Administrative Change"refers to a change to the Contract that does not increase the fees or term
and done in accordance with Section Section 4.01 of these Special Conditions.
"Confidential System Information" means any communication or record (whether oral, written,
electronically stored or transmitted,or in any other form)provided to or made available to Grantee; or that
Grantee may create, receive, maintain, use, disclose or have access to on behalf of HHSC or through
performance of the Project,which is not designated as Confidential Information in a Data Use Agreement.
"State"means the State of Texas and,unless otherwise indicated or appropriate,will be interpreted to mean
HHSC and other agencies of the State of Texas that may participate in the administration of HHSC
Programs;provided,however,that no provision will be interpreted to include any entity other than HHSC
as the contracting agency.
"Software"means all operating system and applications software used or created by Grantee to perform
the work under the Contract.
"Third Party Software" refers to software programs or plug-ins developed by companies or individuals
other than Grantee which are used in performance of the Project. It does not include items which are
ancillary to the performance of the Project, such as internal systems of Grantee which were deployed by
Grantee prior to the Contract and not procured to perform the Project.
"UTC"means HHSC's Uniform Terms and Conditions—Grantee-Version 2.14
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Article II. GRANTEES PERSONNEL
Section 2.01 Qualifications
Grantee agrees to maintain the organizational and administrative capacity and capabilities proposed in its
response to the Solicitation, as modified, to carry out all duties and responsibilities under the Contract.
Grantee Agents assigned to perform the duties and responsibilities under the Contract must be and remain
properly trained and qualified for the functions they are to perform. Notwithstanding the transfer or
turnover of personnel, Grantee remains obligated to perform all duties and responsibilities under the
Contract without degradation and in strict accordance with the terms of the Contract.
Section 2.02 Conduct and Removal
While performing the Project, Grantee Agents must comply with applicable Contract terms, State and
federal rules, regulations, HHSC's policies, and HHSC's requests regarding personal and professional
conduct; and otherwise conduct themselves in a businesslike and professional manner.
If HHSC determines in good faith that a particular Grantee Agent is not conducting himself or herself in
accordance with the terms of the Contract, HHSC may provide Grantee with notice and documentation
regarding its concerns. Upon receipt of such notice,Grantee must promptly investigate the matter and, at
HHSC's election, take appropriate action that may include removing the Grantee Agent from performing
the Project.
Article III. CONFIDENTIALITY
Section 3.01 Confidential System Information
HHSC prohibits the unauthorized disclosure of Other Confidential Information. Grantee and all Grantee
Agents will not disclose or use any Other Confidential Information in any manner except as is necessary
for the Project or the proper discharge of obligations and securing of rights under the Contract. Grantee
will have a system in effect to protect Other Confidential Information. Any disclosure or transfer of Other
Confidential Information by Grantee, including information requested to do so by HHSC, will be in
accordance with the Contract. If Grantee receives a request for Other Confidential Information, Grantee
will immediately notify HHSC of the request, and will make reasonable efforts to protect the Other
Confidential Information from disclosure until further instructed by the HHSC.
Grantee will notify HHSC promptly of any unauthorized possession, use, knowledge, or attempt thereof,
of any Other Confidential Information by any person or entity that may become known to Grantee. Grantee
will furnish to HHSC all known details of the unauthorized possession, use, or knowledge, or attempt
thereof, and use reasonable efforts to assist HHSC in investigating or preventing the reoccurrence of any
unauthorized possession,use,or knowledge,or attempt thereof,of Other Confidential Information.
HHSC will have the right to recover from Grantee all damages and liabilities caused by or arising from
Grantee or Grantee Agents' failure to protect HHSC's Confidential Information as required by this section.
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3.1.17
IN COORDINATION WITH THE INDEMNITY PROVISIONS CONTAINED IN
THE UTC, Grantee WILL INDEMNIFY AND HOLD HARMLESS HHSC FROM
ALL DAMAGES, COSTS, LIABILITIES, AND EXPENSES (INCLUDING
WITHOUT LIMITATION REASONABLE ATTORNEYS' FEES AND COSTS)
CAUSED BY OR ARISING FROM Grantee OR Grantee AGENTS FAILURE TO
PROTECT OTHER CONFIDENTIAL INFORMATION. Grantee WILL FULFILL
THIS PROVISION WITH COUNSEL APPROVED BY HHSC.
Article IV. MISCELLANEOUS PROVISIONS
Section 4.01 Minor Administrative Changes
HHSC's designee, referred to as the Contract Manager, Project Sponsor, or other equivalent, in the
Contract,is authorized to provide written approval of mutually agreed upon Minor Administrative Changes
to the Project or the Contract that do not increase the fees or term. Changes that increase the fees or term
must be accomplished through the formal amendment procedure,as set forth in the UTC. Upon approval
of a Minor Administrative Change, HHSC and Grantee will maintain written notice that the change has
been accepted in their Contract files.
Section 4.02 Conflicts of Interest
Grantee warrants to the best of its knowledge and belief, except to the extent already disclosed to HHSC,
there are no facts or circumstances that could give rise to a Conflict of Interest and further that Grantee or
Grantee Agents have no interest and will not acquire any direct or indirect interest that would conflict in
any manner or degree with their performance under the Contract. Grantee will,and require Grantee Agents,
to establish safeguards to prohibit Contract Agents from using their positions for a purpose that constitutes
or presents the appearance of personal or organizational Conflict of Interest,or for personal gain. Grantee
and Grantee Agents will operate with complete independence and objectivity without actual,potential or
apparent Conflict of Interest with respect to the activities conducted under the Contract.
Grantee agrees that,if after Grantee's execution of the Contract, Grantee discovers or is made aware of a
Conflict of Interest, Grantee will immediately and fully disclose such interest in writing to HHSC. In
addition,Grantee will promptly and fully disclose any relationship that might be perceived or represented
as a conflict after its discovery by Grantee or by HHSC as a potential conflict. HHSC reserves the right to
make a final determination regarding the existence of Conflicts of Interest,and Grantee agrees to abide by
HHSC's decision.
If HHSC determines that Grantee was aware of a Conflict of Interest and did not disclose the conflict to
HHSC,such nondisclosure will be considered a material breach of the Contract. Furthermore,such breach
may be submitted to the Office of the Attorney General,Texas Ethics Commission,or appropriate State or
federal law enforcement officials for further action.
Section 4.03 Flow Down Provisions
Grantee must include any applicable provisions of the Contract in all subcontracts based on the scope and
magnitude of work to be performed by such Subcontractor. Any necessary terms will be modified
appropriately to preserve the State's rights under the Contract.
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Article V. DSHS LEGACY PROVISIONS
Section 5.01 Notice of Criminal Activity and Disciplinary Actions
(a) Grantee shall immediately report in writing to their contract manager when Grantee has knowledge
or any reason to believe that they or any person with ownership or controlling interest in the
organization/business, or their agent, employee, subcontractor or volunteer that is providing
services under this Contract has:
Engaged in any activity that could constitute a criminal offense equal to or greater than a Class A
misdemeanor or grounds for disciplinary action by a state or federal regulatory authority;or
Been placed on community supervision, received deferred adjudication, or been indicted for or
convicted of a criminal offense relating to involvement in any financial matter,federal or state
program or felony sex crime.
(b) Grantee shall not permit any person who engaged, or was alleged to have engaged,in any activity
subject to reporting under this section to perform direct client services or have direct contact with
clients,unless otherwise directed in writing by the System Agency.
Section 5.02 Notice of IRS or TWC Insolvency
Grantee shall notify in writing their assigned contract manager their insolvency,incapacity or outstanding
unpaid obligations to the Internal Revenue Service (IRS) or Texas Workforce Commission within five
days of the date of becoming aware of such.
Section 5.03 Disaster Services
In the event of a local, state, or federal emergency, including natural, man- made, criminal, terrorist,
and/or bioterrorism events, declared as a state disaster by the Governor, or a federal disaster by the
appropriate federal official, Grantee may be called upon to assist the System Agency in providing the
following services:
a. Community evacuation;
b. Health and medical assistance;
c. Assessment of health and medical needs;
d. Health surveillance;
e. Medical care personnel;
f. Health and medical equipment and supplies;
g. Patient evacuation;
h. In-hospital care and hospital facility status;
i. Food,drug and medical device safety;
j. worker health and safety;
k. Mental health and substance abuse;
1. Public health information;
m. Vector control and veterinary services;and
n. Victim identification and mortuary services.
Section 5.04 Consent by Non-Parent or Other State Law to Medical Care of a Minor
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Unless a federal law applies, before a Grantee or its subcontractor can provide medical, dental,
psychological or surgical treatment to a minor without parental consent,informed consent must be obtained
as required by Texas Family Code Chapter 32.
Section 5.05 Services and Information for Persons with Limited English Proficiency
a. Grantee shall take reasonable steps to provide services and information both orally and in
writing,in appropriate languages other than English,to ensure that persons with limited English
proficiency are effectively informed and can have meaningful access to programs,benefits and
activities.
b. Grantee shall identify and document on the client records the primary language/dialect of a
client who has limited English proficiency and the need for translation or interpretation services
and shall not require a client to provide or pay for the services of a translator or interpreter.
c. Grantee shall make every effort to avoid use of any persons under the age of 18 or any family
member or friend of the client as an interpreter for essential communications with a client with
limited English proficiency unless the client has requested that person and using the person
would not compromise the effectiveness of services or violate the client's confidentiality and
the client is advised that a free interpreter is available.
Section 5.06 Third Party Payors
Except as provided in this Contract,Grantee shall screen all clients and may not bill the System Agency for
services eligible for reimbursement from third party payors,who are any person or entity who has the legal
responsibility for paying for all or part of the services provided, including commercial health or liability
insurance carriers,Medicaid,or other federal,state,local and private funding sources.
As applicable,the Grantee shall:
a. Enroll as a provider in Children's Health Insurance Program and Medicaid if providing approved
services authorized under this Contract that may be covered by those programs and bill those
programs for the covered services;
b. Provide assistance to individuals to enroll in such programs when the screening process indicates
possible eligibility for such programs;
c. Allow clients that are otherwise eligible for System Agency services,but cannot pay a deductible
required by a third party payor,to receive services up to the amount of the deductible and to bill the
System Agency for the deductible;
d. Not bill the System Agency for any services eligible for third party reimbursement until all appeals
to third party payors have been exhausted;
e. Maintain appropriate documentation from the third party payor reflecting attempts
to obtain reimbursement;
f. Bill all third party payors for services provided under this Contract before submitting any request for
reimbursement to System Agency;and
g. Provide third party billing functions at no cost to the client.
Section 5.07 HIV/AIDS Model Workplace Guidelines
Grantee shall implement System Agency's policies based on the Human Immunodeficiency
Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS), AIDS Model Workplace Guidelines for
Businesses at http://www.dshs.state.tx.us/hivstd/policy/policies.shtm, State Agencies and State Grantees
Policy No.090.021.
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3.1.17
Grantee shall also educate employees and clients concerning HIV and its related conditions, including
AIDS,in accordance with the Texas.Health& Safety Code §§85.112-114.
Section 5.08 Medical Records Retention
Grantee shall retain medical records in accordance with 22 TAC§165.1(b)or other applicable statutes,rules
and regulations governing medical information.
Section 5.09 Notice of a License Action
Grantee shall notify their contract manager of any action impacting its license to provide services under
this Contract within five days of becoming aware of the action and include the following:
a. Reason for such action;
b. Name and contact information of the local,state or federal department or agency or entity;
c. Date of the license action;and
d. License or case reference number.
Section 5.10 Interim Extension Amendment
a. Prior to or on the expiration date of this Contract, the Parties agree that this Contract can be
extended as provided under this Section.
b. The System Agency shall provide written notice of interim extension amendment to the Grantee
under one of the following circumstances:
1. Continue provision of services in response to a disaster declared by the governor;or
2. To ensure that services are provided to clients without interruption.
c. The System Agency will provide written notice of the interim extension amendment that specifies
the reason for it and period of time for the extension.
d. Grantee will provide and invoice for services in the same manner that is stated in the Contract.
e. An interim extension under Section(b)(1)above shall extend the term of the contract not longer
than 30 days after governor's disaster declaration is declared unless the Parties agree to a shorter
period of time.
f. An interim extension under Section(b)(2)above shall be a one-time extension for a period
of time determined by the System Agency.
Section 5.11 Child Abuse Reporting Requirement
a. Grantees shall comply with child abuse and neglect reporting requirements in Texas Family Code
Chapter 261. This section is in addition to and does not supersede any other legal obligation of
the Grantee to report child abuse.
b. Grantee shall develop, implement and enforce a written policy that includes at a minimum the
System Agency's Child Abuse Screening, Documenting, and Reporting Policy for
Grantees/Providers and train all staff on reporting requirements.
c. Grantee shall use the System Agency's Child Abuse Reporting Form located at www.System
Agency.state.tx.us/childabusereporting as required by the System Agency. Grantee shall retain
reporting documentation on site and make it available for inspection by the System Agency.
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Section 5.12 Grantee's Certification of Meeting or Exceeding Tobacco-Free Workplace
Policy Minimum Standards
Grantee certifies that it has adopted and enforces a Tobacco-Free Workplace Policy that meets or
exceeds all of the following minimum standards of:
a) Prohibiting the use of all forms of tobacco products, including but not limited to cigarettes,
cigars, pipes, water pipes (hookah), bidis, kreteks, electronic cigarettes, smokeless tobacco,
snuff and chewing tobacco;
b) Designating the property to which this Policy applies as a "designated area," which must at
least comprise all buildings and structures where activities funded under this Contract are
taking place,as well as Grantee owned,leased,or controlled sidewalks,parking lots,walkways,
and attached parking structures immediately adjacent to this designated area;
c) Applying to all employees and visitors in this designated area;and
d) Providing for or referring its employees to tobacco use cessation services.
If Grantee cannot meet these minimum standards,it must obtain a waiver from the System Agency.
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Attachment E — General Affirmations
ATTACHMENT
GENERAL AFFIRMATIONS
By entering into this Contract,Contractor affirms,without exception,as follows:
1. Contractor represents and warrants that these General Affirmations apply to Contractor and all of
Contractor's principals, officers, directors, shareholders, partners, owners, agents, employees,
Subcontractors, independent contractors, and any other representatives who may provide services
under,who have a financial interest in,or otherwise are interested in this Contract.
2. Contractor represents and warrants that all statements and information provided to the System Agency
are current, complete, and accurate. This includes all statements and information relating in any
manner to this Contract and any solicitation resulting in this Contract.
3. Contractor has not given,has not offered to give, and does not intend to give at any time hereafter any
economic opportunity, future employment, gift, loan, gratuity, special discount, trip, favor, or service
to a public servant in connection with this Contract.
4. Under Section 2155.004, Texas Government Code (relating to financial participation in preparing
solicitations), Contractor certifies that it is not ineligible to receive this Contract and acknowledges
that this Contract may be terminated and payment withheld if this certification is inaccurate.
5. Under Section 2155.006, Texas Government Code (relating to convictions and penalties regarding
Hurricane Rita, Hurricane Katrina, and other disasters), Contractor certifies that it is not ineligible to
receive this Contract and acknowledges that this Contract may be terminated and payment withheld if
this certification is inaccurate.
6. Under Section 2261.053, Texas Government Code (relating to convictions and penalties regarding
Hurricane Rita, Hurricane Katrina, and other disasters), Contractor certifies that it is not ineligible to
receive this Contract and acknowledges that this Contract may be terminated and payment withheld if
this certification is inaccurate.
7. Under Section 231.006, Texas Family Code (relating to delinquent child support), Contractor certifies
that it is not ineligible to receive the specified grant, loan, or payment and acknowledges that this
Contract may be terminated and payment may be withheld if this certification is inaccurate.
8. Contractor certifies that: (a)the entity executing this Contract; (b)its principals; (c)its Subcontractors;
and (d) any personnel designated to perform services related to this Contract are not presently
debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
participation in this transaction by any federal Department or Agency. This certification is made
pursuant to the regulations implementing Executive Order 12549 and Executive Order 12689,
Debarment and Suspension, 2 C.F.R. Part 376, and any relevant regulations promulgated by the
Department or Agency funding this project. This provision shall be included in its entirety in
Contractor's Subcontracts if payment in whole or in part is from federal funds.
9. Contractor certifies that it, its principals, its Subcontractors, and any personnel designated to perform
services related to this Contract are eligible to participate in this transaction and have not been
subjected to suspension, debarment, or similar ineligibility determined by any federal, state, or local
governmental entity.
10. Contractor certifies it is in compliance with all State of Texas statutes and rules relating to
procurement; and that (a) the entity executing this Contract; (b) its principals; (c) its Subcontractors;
and (d) any personnel designated to perform services related to this Contract are not listed on the
federal government's terrorism watch list described in Executive Order 13224. Entities ineligible for
federal procurement are listed at https://www.sam.gov/portal/public/SAM/, which Contractor may
review in making this certification. Contractor acknowledges that this Contract may be terminated and
payment withheld if this certification is inaccurate. This provision shall be included in its entirety in
Contractor's Subcontracts if payment in whole or in part is from federal funds.
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3.1.17
ATTACHMENT
GENERAL AFFIRMATIONS
11. In accordance with Texas Government Code Section 669.003 (relating to contracting with the
executive head of a state agency), Contractor certifies that it (1) is not the executive head of the
System Agency; (2) was not at any time during the past four years the executive head of the System
Agency;and(3)does not employ a current or former executive head of the System Agency.
12. Contractor represents and warrants that it is not currently delinquent in the payment of any franchise
taxes owed the State of Texas under Chapter 171 of the Texas Tax Code.
13. Contractor represents and warrants that payments to Contractor and Contractor's receipt of
appropriated or other funds under this Contract are not prohibited by Sections 556.005, 556.0055, or
556.008 of the Texas Government Code (relating to use of appropriated money or state funds to
employ or pay lobbyists,lobbying expenses,or influence legislation).
14. Contractor represents and warrants that it will comply with Texas Government Code Section
2155.4441,relating to the purchase of products produced in the State of Texas under service contracts.
15. Pursuant to Section 2252.901, Texas Government Code (relating to prohibitions regarding contracts
with and involving former and retired state agency employees), Contractor will not allow any former
employee of the System Agency to perform services under this Contract during the twelve(12)month
period immediately following the employee's last date of employment at the System Agency.
16. Contractor acknowledges that, pursuant to Section 572.069 of the Texas Government Code, a former
state officer or employee of the System Agency who during the period of state service or employment
participated on behalf of the System Agency in a procurement or contract negotiation involving
Contractor may not accept employment from Contractor before the second anniversary of the date the
officer's or employee's service or employment with the System Agency ceased.
17. Contractor understands that the System Agency does not tolerate any type of fraud. The System
Agency's policy is to promote consistent, legal, and ethical organizational behavior by assigning
responsibilities and providing guidelines to enforce controls. Violations of law, agency policies, or
standards of ethical conduct will be investigated,and appropriate actions will be taken. All employees
or contractors who suspect fraud, waste or abuse (including employee misconduct that would
constitute fraud, waste, or abuse) are required to immediately report the questionable activity to both
the Health and Human Services Commission's Office of the Inspector General at 1-800-436-6184 and
the State Auditor's Office.Contractor agrees to comply with all applicable laws,rules,regulations, and
System Agency policies regarding fraud including,but not limited to,HHS Circular C-027.
18. Contractor represents and warrants that it has not violated state or federal antitrust laws and has not
communicated its bid for this Contract directly or indirectly to any competitor or any other person
engaged in such line of business. Contractor hereby assigns to System Agency any claims for
overcharges associated with this Contract under 15 U.S.C. § 1, et seq., and Texas Business and
Commerce Code § 15.01,et seq.
19. Contractor represents and warrants that it is not aware of and has received no notice of any court or
governmental agency proceeding, investigation, or other action pending or threatened against
Contractor or any of the individuals or entities included numbered paragraph 1 of these General
Affirmations within the five (5) calendar years immediately preceding the execution of this Contract
that would or could impair Contractor's performance under this Contract, relate to the contracted or
similar goods or services, or otherwise be relevant to the System Agency's consideration of entering
into this Contract. If Contractor is unable to make the preceding representation and warranty, then
Contractor instead represents and warrants that it has provided to the System Agency a complete,
detailed disclosure of any such court or governmental agency proceeding,investigation,or other action
that would or could impair Contractor's performance under this Contract, relate to the contracted or
similar goods or services, or otherwise be relevant to the System Agency's consideration of entering
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3.1.17
ATTACHMENT
GENERAL AFFIRMATIONS
into this Contract. In addition, Contractor represents and warrants that it shall notify the System
Agency in writing within five (5)business days of any changes to the representations or warranties in
this clause and understands that failure to so timely update the System Agency shall constitute breach
of contract and may result in immediate termination of this Contract.
20. Contractor understands, acknowledges, and agrees that any false representation or any failure to
comply with a representation, warranty, or certification made by Contractor is subject to all civil and
criminal consequences provided at law or in equity including, but not limited to, immediate
termination of this Contract.
21. Contractor represents and warrants that it will comply with all applicable laws and maintain all permits
and licenses required by applicable city, county, state, and federal rules, regulations, statues, codes,
and other laws that pertain to this Contract.
22. Contractor represents and warrants that the individual signing this Contract is authorized to sign on
behalf of Contractor and to bind Contractor.
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Attachment G — System Agency Solicitation
No. 537-16-142081
) TEXAS
611„ ( Health and Human
Services commission
Kyle L. Janek, M.D., Executive Commissioner
Request for Proposals (RFP)
For
Primary Health Care Program
RFP No. 537-16-142081
Date of Release: April 1, 2015
CPA Class/Item Codes: 193-66
260-82
948-27
948-28
948-32
948-47
948-48
948-97
952-42
952-43
952-88
952-90
952-94
958-56
961-48
Page 1 PHC RFP#537-16-142081
TABLE OF CONTENTS
PROPOSAL INFORMATION 4
I. INTRODUCTION AND DEFINITIONS 4
A. Eligible Respondents 13
B. Term of Contract 14
C. Use of Funds 14
D. Schedule of Events 17
II. PROGRAM INFORMATION 18
A. General Purpose and Program Goals—Scope of Work 18
B. Legal Authority 18
C. Program Requirements 19
III. PROCUREMENT REQUIREMENTS 21
A. RFP Point of Contact 21
B. Proposal Conference 22
C. Proposal Due Date 22
D. Submission 22
IV. PROPOSAL SCREENING AND EVALUATION 23
A. Screening Process 23
B. Evaluation Process 24
C. Evaluation Criteria 25
D. Selection, Negotiation, and Award 25
V. HHSC ADMINISTRATIVE INFORMATION 26
A. Rejection of Proposals 26
B. Right to Amend or Withdraw RFP 26
C. Authority to Bind DSHS 26
D. Financial and Administrative Requirements 27
E. Contracting with Subcontractors 28
F. DSHS Historically Utilized Business Participation 28
G. Contract Information 34
H. Contract Award Protest Procedures 34
CONTENT AND PREPARATION 35
VI. PROPOSAL CONTENT 35
Page 2 PHC RFP#537-16-142081
A. Instructions for Preparation 35
B. Confidential Information 35
C. Table of Contents 36
VII. BLANK FORMS AND INSTRUCTIONS 37
FORM A: FACE PAGE 38
FORM A: FACE PAGE INSTRUCTIONS 39
FORM A-1: TEXAS COUNTIES AND REGIONS LIST 40
FORM B: PROPOSAL TABLE OF CONTENTS AND CHECKLIST 42
FORM C: PHC CONTACT PERSON INFORMATION 43
FORM D: ADMINISTRATIVE INFORMATION 44
FORM D-1: GOVERNMENTAL ENTITY 48
FORM D-2: NONPROFIT OR FOR-PROFIT ENTITY 49
FORM E: EXCEPTIONS FORM 50
FORM F: RESPONDENT BACKGROUND 52
FORM G: ASSESSMENT NARRATIVE 53
FORM H: PERFORMANCE MEASURES 54
FORM I: WORK PLAN 56
FORM I: WORK PLAN GUIDELINES 57
FORM J: CHILD SUPPORT CERTIFICATION 58
FORM K: FINANCIAL MANAGEMENT AND ADMINISTRATION 59
QUESTIONNAIRE
FORM L: PHC CLINIC SITES Instructions 63
FORM L: PHC CLINIC SITES 64
FORM L-1: PHC CLINIC SITE READINESS 65
APPENDICES 66
APPENDIX A: BUDGET SECTION 66
APPENDIX B: DSHS ASSURANCES AND CERTIFICATIONS 67
APPENDIX C: HUB REQUIREMENTS 73
Page 3 PHC RFP#537-16-142081
PROPOSAL INFORMATION
INTRODUCTION AND DEFINITIONS
The Health and Human Services Commission (HHSC) on behalf of the Department of
State Health Services (DSHS or Department) Community Health Services Section,
Preventive and Primary Care Unit (Program) announces the expected availability of
State Fiscal Year (FY) 2016 Primary Health Care (PHC) funds to provide
comprehensive primary care services to eligible individuals for the purpose of
prevention, early detection, and intervention of health problems (Project). This Request
for Proposal (RFP) is not limited to this source of funding if other sources become
available for this Project.
DSHS PHC services are intended to ensure that low-income Texas residents, whose
gross family income is at or below 200% of the adopted federal poverty income
guidelines and who are not eligible for similar services through any other publicly
funded programs/benefits, have access to primary health care. Priority PHC services
include diagnosis and treatment; emergency services; family planning services;
preventive health services, including immunizations; health education; and laboratory,
x-ray, nuclear medicine, or other appropriate diagnostic services. Specific requirements
related to the provision of PHC services can be found online in the DSHS Primary
Health Care Policy Manual at: http://www.dshs.state.tx.us/phc/pandp.shtm
This RFP contains the requirements that all respondents must meet to be considered
for contracts under this RFP. Failure to comply with these requirements will result in
disqualification of the respondent without further consideration. Each respondent is
solely responsible for the preparation and submission of a proposal in accordance with
instructions contained in this RFP.
Before completing the proposal, refer to the relevant program standards provided in
SECTION II. PROGRAM INFORMATION. Other sections within the RFP may contain
additional instructions pertaining to unique program requirements set forth in legislation
or regulations, etc. If web links in this document do not open, copy and paste
them into your internet browser window.
PLEASE READ ALL MATERIALS BEFORE PREPARING THE PROPOSAL.
Page 4 PHC RFP#537-16-142081
Definitions
Appendix — Additional information and/or forms that are available at the end of this
solicitation document.
Budget —A financial schedule documented in the contract that describes how funds will
be used and/or describes the basis for reimbursement for the provision of contracted
services. Types of budget may include categorical (line item), fee for service, or lump
sum. The Budget Section is required and is posted with this RFP as a separate
package on the HHSC Business Opportunities website.
Budget Period — The duration of the budget (stated in the number of months the
contract will reflect from begin date to end date of the term of the contract). Each
contract renewal will have its own budget period.
Contract — A written document referring to promises or agreements for which the law
establishes enforceable duties and remedies between a minimum of two parties. A
DSHS contract is assembled using a core contract (base), one or more program
attachments, and other required exhibits (general provisions, etc.)
Contractor — An individual, organization, or entity that contracts with DSHS to provide
services and/or goods. This includes (but is not limited to) vendors, sub-recipients, and
grantees.
Contract Term — The period of time during which the contract or program attachment
will be effective from begin date to end, or renewal date. The contract term may or may
not be the same as the budget period.
Cost Reimbursement — A payment mechanism by which contractors are reimbursed
for allowable costs incurred up to the total award amount specified in the contract.
Costs must be incurred in carrying out approved activities, and must be based on an
approved eight -category line-item (categorical) budget. Amounts expended in support
of providing services and goods, if any, in accordance with the contract terms and
conditions must be billed on a monthly basis for reimbursement unless otherwise
specified in the contract. Reimbursement is based on actual allowable costs incurred
that comply with the cost principles applicable to the grant and subgrants.
Debarment — An exclusion from contracting or subcontracting with state agencies on
the basis of cause set forth in Title 34, Texas Administrative Code Chapter 20,
Subchapter C, §20.105 et seq.
Deliverables — Goods or services contracted for delivery or performance.
Due Date — Established deadline for submission of a document or deliverable.
Effective Date — The date the contract term begins.
Fee For Service — Payment mechanism for services that are reimbursed on a set rate
per unit of service (also known as unit rate). Fee-for-service reimbursement rates may
Page 5 PHC RFP#537-16-142081
be based on a prescribed set of Current Procedural Terminology (CPT) codes and
Medicaid fee-for-service physician reimbursement rates.
Fully Executed — When a contract is signed by each of the parties to form a legal
binding contractual relationship. No costs chargeable to the proposed contract will be
reimbursed before the contract is fully executed.
Indirect Costs — Costs incurred for a common or joint purpose benefiting more than
one project or cost objective of respondent's organization and not readily identified with
a particular project or cost objective. Typical examples of indirect costs may include
general administration and general expenses such as salaries and expenses of
executive officers, personnel administration and accounting; depreciation or use
allowances on buildings and equipment; and costs of operating and maintaining
facilities.
General Provisions — Basic provisions that are essential in administering the contract,
which include assurances required by law, compliance requirements, applicable federal
and state statutes and circulars, financial management standards, records and
reporting requirements, funding contingency, sanctions, and terms and conditions of
payment.
Procurement and Contracting Services Division (PCS) - Central contracting unit
within HHSC that is responsible for statewide procurements and their certifications.
PCS oversees, coordinates, and assists the Divisions with procurement needs, issues
competitive procurements, finalizes development, and executes contracts. PCS
maintains the official contract file from procurement to contract closeout.
Program — Depending upon the context, either a coordinated group of activities carried
out by DSHS, as authorized by state or federal law, for a specific purpose (program) or
DSHS staff located in a program, region, or hospital that identify and request
procurement needs (Program) The Program partners with PCS on procurements.
Program Attachment — An attachment to the contract that provides details for a
particular statement of work to be performed under the contract such as services to be
delivered, performance measures or deliverables, funding, and reporting requirements.
There may be multiple program attachments associated with a core contract. A
program attachment is typically for a one-year term, with a contracting cycle made up of
several one-year program attachment renewals.
Project—All work to be performed as a result of a contract or solicitation.
Project Period — The anticipated duration of the entire Project stated in total number of
budget periods.
Respondent — A person or entity that submits a response to a solicitation. For
purposes of this document, "respondent" is intended to include such phrases as
"offeror", "bidder", "responder", or other similar terminology employed by DSHS (or
HHSC) to describe the person or entity that responds to a solicitation.
Page 6 PHC RFP#537-16-142081
Scope of Work — A description of the services and/or goods, if any, for each service
type, to be obtained as a result of a solicitation for a project period. The scope of work
is a document written in the early stages of procurement to explain what DSHS plans to
purchase.
Solicitation — The process of notifying prospective contractors of an opportunity to
provide goods or services to the state (e.g., this RFP).
Special Provisions — Modifications and additions to the General Provisions for a
funded program activity; which are usually customized for the Program's requirements
and contain provisions specific to the program attachment.
Statement of Work — The part of the contract that describes the services and/or goods
to be delivered by the DSHS contractor specifying the type, level and quality of
service, that directly relate to program objectives.
Subcontract — A written agreement between the DSHS contractor and a third party to
provide all or a specified part of the services, goods, work, and materials required in the
original contract. The contractor remains entirely responsible to DSHS for performance
of all requirements of the contract with DSHS. The contractor must closely monitor the
subcontractor's performance. Subcontracting can be done only when expressly
allowed in the program attachment.
Subrecipient — A type of contractor or subcontractor to which a subaward is made in
the form of money, or property in lieu of money, to carry out all or part of the DSHS
Program and that is accountable to DSHS for the use of the funds and property
provided. This type of contractor may also be referred to as a subgrantee.
Reimbursement is based on actual allowable costs incurred that comply with cost
principles applicable to the grants and subgrants.
A subrecipient contractor will have most of the following characteristics: a) determines
who is eligible to receive what assistance, according to specified criteria; b) has
performance measured against federal or state program objectives, as described in the
program attachment; c) has responsibility for programmatic decision-making, and d)
carries out duties to implement all or part of a program, as specified.
Supplant (verb) - To replace or substitute one source of funding for another source of
funding. A recipient of contract funds under this RFP must not use the funds to pay any
costs that the recipient is already obligated to pay. If a contractor, prior to responding
to an RFP, had committed to provide funding for activities defined in the contract's
statement of work (i.e., as represented in the RFP Budget Summary), then the
contractor must provide the amount of funding previously committed in addition to the
amount requested under this RFP.
Unit Rate — Payment mechanism for services that are reimbursed at a set rate per unit
of service; for example, treatment services at a prescribed rate per hour (also known as
fee-for-service).
Page 7 PHC RFP#537-16-142081
Vendor — A type of contractor or subcontractor that provides services, and goods, if
any, that assist in, but are not the primary means of, carrying out the DSHS-funded
Program. Under a vendor contract, the vendor will have few if any administrative
requirements. (For example, a vendor might be required only to submit a summary
report of services delivered and an invoice.) A vendor generally will deliver services to
DSHS-funded clients in the same manner the vendor would deliver those services to its
non-DSHS-funded clients.
A vendor contractor generally has most of the following characteristics: a) provides
goods and services within normal business operations, b) provides similar goods and
services to many different purchasers, c) operates in a competitive environment, d) is
not subject to compliance requirements of the federal or state program, e) provides
goods and services that are ancillary to the operation of the program. Note:
Characteristics a, b, c, and d do not apply to vendor contractors that are universities.
Vendor Identification Number (Vendor ID No.) — Fourteen-digit number needed for
any entity, whether vendor or subrecipient, to contract with the State of Texas and
which must be established with the State Comptroller's Office. It consists of a ten-digit
identification number (IRS number, state agency number, or social security number)
+check digit + 3 digit mail code. The Vendor ID No. includes all the numbers in the
TINs (defined above), including a three digit mail code for a total of 14-digits.
Work Plan - A plan that describes how services will be delivered to the eligible
population and includes specifics such as what types of clients will be served, who will
be responsible for the work, timelines for completion of activities, and how services will
be evaluated when complete. To be an enforceable part of the contract, details from the
work plan must be approved by DSHS and incorporated in the contract.
Program Definitions
Barrier to Care — a factor that hinders a person from receiving health care (i.e.,
proximity (or distance), lack of transportation, documentation requirements, co-payment
amount, etc.).
Class D (Clinic) Pharmacy License — A pharmacy license issued to a pharmacy to
dispense a limited type of drug or devices under a prescription drug order (e.g., XYZ
Health Clinic). Information to apply for a Class D Pharmacy License may be found at:
http://www.tsbp.state.tx.us/files pdf/INSTRUCTIONS CLASS D PHY.pdf.
Client - An individual who has been screened, determined to be eligible for services,
and successfully completed the eligibility process.
Community Assessment — Tool used to identify factors that affect the health of a
population and to determine the availability of resources within the community to impact
these factors.
Contraception —The means of pregnancy prevention, including permanent and
temporary methods.
Page 8 PHC RFP#537-16-142081
Contractor — For program purposes, the entity the Department of State Health
Services has contracted with to provide services. The contractor is the responsible
entity even if there is a subcontractor involved who actually provides the services.
Co-payment (co-pay) - Monies collected directly from clients for services. The amount
collected each month shall be deducted from the Monthly Purchase Voucher (Form B -
13) and is considered program income.
Dental Services — Diagnostic, preventive, and therapeutic dental services that are
provided to eligible individuals and are performed in a dental office or clinic.
Diagnosis — The recognition of disease status determined by evaluating the history of
the client and the disease process, and the signs and symptoms present. Determining
the diagnosis may require microscopic (i.e., culture), chemical (i.e., blood tests), and/or
radiological examinations (x-rays).
Diagnosis and Treatment — Diagnosis and treatment of common acute and chronic
disease that affect the general health of the client. Services include first contact with a
client for an undiagnosed health concern as well as continuing care of varied medical
conditions not limited by cause or organ system. Services must not be limited to
specialized care such as family planning services only.
Diagnostic Services — Activities related to the diagnosis made by a physician,
Advanced Practice Nurse (APN) or Physician Assistant (PA), which may also be
performed by nurses or other health professionals.
Diagnostic Studies or Diagnostic Tests — Tests ordered by the client's health care
practitioner(s) to evaluate an individual's health status for diagnostic purposes.
Eligibility Date — Date the individual submits a completed application to the provider.
The eligibility expiration date is twelve months from the eligibility date.
Emergency Services — Urgent care services provided for an unexpected health
condition requiring immediate attention. Clinical emergency situations include
conditions such as anaphylaxis, syncope, cardiac arrest, shock, hemorrhage, and
respiratory difficulties and in response to environmental emergencies (including natural
and man-made disaster situations).
Environmental Health — As defined by the World Health Organization, "Environmental
health addresses all the physical, chemical, and biological factors external to a person,
and all the related factors impacting behaviors. It encompasses the assessment and
control of those environmental factors that can potentially affect health. It is targeted
towards preventing disease and creating health-supportive environments. This
definition excludes behavior not related to environment, as well as behavior related to
the social and cultural environment, and genetics."
http://www.who.int/topics/environmental_health/en/
Page 9 PHC RFP#537-16-142081
Family Planning Services — Services that assist women and men in planning their
families, whether it is to achieve, postpone, or prevent pregnancy. Family planning
services should include the following: pregnancy test (if indicated), health history,
physical examinations, basic infertility services, lab tests, STD services (including
HIV/AIDS), and other preconception health services (e.g. screening for obesity,
smoking, and mental health), counseling/education, and contraceptive supplies.
Federal Poverty Level (FPL) —The set minimum amount of income that a family needs
for food, clothing, transportation, shelter and other necessities. In the United States
(U.S.), this level is determined by the Department of Health and Human Services. FPL
varies according to family size. The number is adjusted for inflation and reported
annually in the form of poverty guidelines. Public assistance programs, such as
Medicaid, define eligibility income limits as some percentage of FPL.
Fiscal Year— State fiscal year, September 1 —August 31.
Good Faith Effort —Sustained effort made with deliberate intention to produce desired
or required result. Agencies or entities must make a 'good faith effort' in such functions
as client follow-up, client referrals, and other clinical operations as defined in policy,
contract, and contractor proposal.
Health Education — The process of educating or teaching individuals about lifestyles
and daily activities that promote physical, mental, and social well-being. This process
may be provided to an individual or to a group of individuals.
Health and Human Services Commission (HHSC) — State agency with administration
and oversight responsibilities for designated Health and Human Services agencies,
including DSHS.
Health Screening — The provision of tests (i.e., blood glucose, serum cholesterol, etc.)
as a means of determining the need for intervention and possibly a more
comprehensive evaluation.
Health Service Region (HSR) — For administrative purposes, DSHS has grouped
counties within specified geographic areas into 8 Health Service Regions.
Home Health Care — An array of services provided by health care professionals in a
patient's home. Services may include skilled nursing care visits, prescribed by a
physician and provided by a Registered Nurse (RN), to observe, assess, evaluate and
treat a patient, or visits by a home health aide to assist with administering medication.
Laboratory - (informally, lab) Facility that measures or examines materials derived from
the human body for the purpose of providing information on diagnosis, monitoring
prevention or treatment of disease.
Laboratory, X-Ray, or other Appropriate Diagnostic Services — Studies or tests
ordered by the client's health care practitioner(s) (e.g.; physicians, dentists, mid-level
providers) to evaluate an individual's health status for diagnostic purposes.
Medicaid — Title XIX of the Social Security Act; reimburses for health care services
Page 10 PHC RFP#537-16-142081
delivered to low-income clients who meet eligibility guidelines.
Minor — In Texas, a minor is a person under 18 years of age who has never been
married and never been declared an adult by a court (emancipated). See Texas Family
Code Sections 101 .003, 31.001-31.007, 32.003-004, and 32.202.
Nutritional Services — The provision of services to identify the nutritional status of an
individual, and instruction which includes appropriate dietary information based on the
client's needs, (i.e., age, sex, health status, culture). Information may be provided on
an individual one- to-one basis, or to a group of individuals.
Outreach — Activities that are conducted with the purpose of informing and educating
the community about services and increasing the number of participants.
Patient— An individual who is eligible to receive medical care, treatment, or services.
Podiatry Services — The study and care of the foot, including its anatomy, pathology,
and medical/surgical treatment.
Prescription Drugs, Devices and/or Durable Supplies — Medically necessary
pharmaceuticals devices and/or medical supplies (capable of withstanding wear) which
are needed for the treatment of a diagnosed condition.
Presumptive Eligibility — Short-term availability and access to health care services (up
to 90 days) when the client screens potentially eligible for services but lacks verification
to achieve full eligibility.
Preventive Health Care Services — Medical care that focuses on disease prevention
and health maintenance, including early diagnosis of disease, discovery and
identification of people at risk of development of specific problems, counseling, and
other necessary intervention to avert a health problem. Included are screening tests,
immunizations, risk assessments, health histories and baseline physicals for early
detection of disease and restoration to a previous state of health, and prevention of
further deterioration and/or disability.
Program Income — Monies collected directly by the contractor/provider for services
provided under the grant award (i.e., fees or charges collected from clients that are
made in connection with the delivery of program services). All program income must be
used by the contractor during the contract year to further the operation of the program
for which the contract was executed. The RFP contains additional program
requirements pertaining to program income.
Provider— An individual clinician or group of clinicians who provide services.
Readiness — Respondent has the specified attributes to support a given service, the
ability to meet program and contractual requirements, and the capacity to achieve
service levels based on awarded funds.
Re-certification — The process of re-screening and determining eligibility for the next
Page 11 PHC RFP#537-16-142081
year.
Resident Alien — A person who is not a U.S. citizen and has a valid immigration
document.
Service — Any client encounter at a facility that results in the client having a medical or
health-related need met.
Social Services — The provision of counseling and guidance; assistance to client and
family in locating, accessing, and utilizing appropriate community resources.
Texas Medicaid and Healthcare Partnership (TMHP) — The Texas Medicaid Claims
and Primary Care Case Management (PCCM) administrator. HHSC contracts with
TMHP to process claims for providers.
Texas Women's Health Program (TWHP) - The TWHP is a state-funded program,
administered by HHSC, to provide uninsured women with family planning exams,
related health screenings, and birth control.
Texas Resident — An individual who resides within the geographic boundaries of the
state.
Transportation — Services provided to a client for the purpose of receiving a required
health care service. Transportation could be provided via private vehicle, public
transportation, project site vehicle, or emergency medical vehicle.
Treatment — Any specific procedure used for the cure or the improvement of a disease
or pathological condition.
Undocumented Alien — A person living in the U.S. without the knowledge and
permission of the U.S. Bureau of Citizenship and Immigration Services.
Unduplicated Client — A client counted only one time during the program's fiscal year,
regardless of the number of visits, encounters, or services they receive. For example,
one client seen four times during the year is counted as one unduplicated client.
Page 12 PHC RFP#537-16-142081
A. Eligible Respondents
Eligible respondents include any public or private nonprofit, governmental entity, or for-profit
entity that can meet the requirements described in Sections I and II of this RFP and must
comply with the criteria listed below.
1. Respondent must be established as an appropriate legal entity as described in
the paragraph above, under state statutes and must have the authority and be in
good standing to do business in Texas and to conduct the activities described in the
RFP.
2. Respondent must have a Texas business address. A post office box may be
used when the proposal is submitted, but the respondent must conduct business at
a physical location in Texas prior to the date that the contract is awarded.
3. Respondent must be in good standing with the U.S. Internal Revenue Service.
4. Respondent is not eligible to apply for funds under this RFP if currently debarred,
suspended, or otherwise excluded or ineligible for participation in Federal or State
assistance programs.
5. Respondent may not be eligible for contract award if audit reports or financial
statements submitted with the proposal identify concerns regarding the future
viability of the contractor, material non-compliance or material weaknesses that are
not satisfactorily addressed, as determined by DSHS.
6. Respondent's staff members, including the executive director, must not serve as
voting members on their employer's governing board.
7. In compliance with Comptroller of Public Accounts and Texas Procurement and
Support Services rules, a name search will be conducted using the websites listed
in this section prior to the development of a contract.
A respondent is not considered eligible to contract with DSHS, regardless of the
funding source, if a name match is found on any of the following lists:
a) The General Services Administration's (GSA) System for Award
Management (SAM) for parties excluded from receiving federal
contracts, certain subcontracts and from certain types of federal
financial and non-financial assistance and benefits.
https://www.sam.gov/portal/public/SAM
b) The Office of Inspector General (OIG) List of Excluded
Individuals/Entities Search— State
https://oig.hhsc.state.tx.us/Exclusions/search.aspx; and
c) Texas Comptroller of Public Accounts (CPA) Debarment List
located at
http://www.window.state.tx.us/procurement/prog/vendor_performan
ce/ debarred/. If this web link does not open, copy and paste to
your internet browser window.
Page 13 PHC RFP#537-16-142081
8. Respondents must be listed on the following list if they are Professional
Corporations, Professional Associations, Texas Corporations, and/or Texas Limited
Partnership Companies. Secretary of State (SOS) at
https://direct.sos.state.tx.us/acct/acct-login.asp.
Except as expressly provided in A.2. above, respondent is not considered eligible to
apply unless the respondent meets the eligibility conditions to the stated criteria
listed above at the time the proposal is submitted. Respondent must continue to
meet these conditions throughout the selection and funding process. DSHS
expressly reserves the right to review and analyze the documentation submitted and
to request additional documentation, and determine the respondent's eligibility to
compete for the contract award.
B. Term of Contract
It is expected that the initial contract term will begin on or about 09/01/15, and will be made for
a 12-month budget period. This contract may be renewed up to 4 additional one year
period(s), with renewal initiated at the sole discretion of DSHS. Continued funding of the
contract in future years is contingent upon the availability of funds and the satisfactory
performance of the contractor during the prior contract period. Funding may vary and is
subject to change each renewal.
Contracts awarded under this RFP and any anticipated contract renewals are contingent upon
the continued availability of funding. DSHS reserves the right to alter, amend or withdraw this
RFP at any time prior to the execution of a contract if funds become unavailable through lack
of appropriations, budget cuts, transfer of funds between programs or agencies, amendment
of the appropriations act, health and human services agency consolidations, or any other
disruption of current appropriations. If a contract has been fully executed and these
circumstances arise, the provisions of the Termination Article in the contract General
Provisions will apply.
C. Use of Funds
In Fiscal Year 2016, approximately $11.5M is expected to be available. The specific
dollar amount awarded to each successful respondent depends upon the merit and
scope of the proposal and other best value considerations and is at the sole
discretion of DSHS.
Funds are awarded for the purpose specifically defined in this RFP and must not be
used for any other purpose. Funds may be used for personnel, fringe benefits, staff
travel, contractual services, other direct costs, and indirect costs, as allowed in the
budget.
NOTE: All respondents must include funds in the Travel budget category for one
required in-state meeting (The Community Health Services Section Clinical
Conference). Respondent should plan for 2 staff to attend the meeting for 2 days;
place to be determined. DSHS PHC Contractor Projects must provide the priority
Page 14 PHC RFP#537-16-142081
PHC services in primary health care clinics in Texas.
Funds must not be used to supplant other local, state, or federal funds.
Respondent's request for state funds in this RFP, and the proposed PHC project,
must be based on an assessment of current community needs and identified gaps in
the established community primary care delivery system for the target population of
low-income individuals at or below 200% of the adopted Federal Poverty Income
Level (FPL) guidelines.
Contractors must ensure that all funds awarded are utilized for DSHS primary care
services. To prevent underutilization of funds, DSHS reserves the right to require
contractors to return unused funds for re-allocation if it is determined that the
contractor cannot reasonably utilize all funds initially awarded.
According to 25 Texas Administrative Code, §§39.2, 39.3, and 39.4, all providers
shall offer the following priority and optional services directly or by subcontract
and/or referral at no additional cost to the client:
Priority Services that must be provided with PHC funds either directly or by
subcontract and referral:
• Preventive health services including immunizations;
• Diagnosis and treatment;
• Family planning;
• Health education;
• Diagnostic tests, including laboratory, x-ray, nuclear medicine, or
other appropriate diagnostic services; and
• Emergency services.
Optional services that may be funded in addition to the priority services
above include:
• Prescription drugs, medical devices, and durable supplies;
• Transportation;
• Dental care;
• Podiatry services;
• Nutritional services;
• Home health care;
• Environmental health services; and
• Social services.
DSHS PHC Contractor Projects are intended to address access to primary health
care services and to prevent duplication of services by coordinating authorized
primary health care services with existing federal, state, and local programs.
Page 15 PHC RFP#537-16-142081
Funds must not be used to supplant other local, state, or federal funds.
Reimbursement for PHC Services
A claim-based, automated system for submission and reimbursement of PHC clinical
services may be developed during the project period for this procurement. Prior to
implementation, the initial contract for each awardee from this RFP will be a cost
reimbursement contract. Payments will be made for allowable costs incurred and will be
supported by reporting the services provided and client-level data. Upon full
implementation of this system, reimbursement for services procured by this RFP will be
available by two methods: fee-for-service and cost reimbursement; contractors will be
required to use the automated system as the fee-for-service billing system and the client
services reporting system for PHC.
At that time, each awardee will be required to have a percentage (determined by DSHS)
of their remaining funds for the current contract year and subsequent renewal periods
moved to a separate, fee-for-service contract for reimbursement of clinical services
through the automated system at Medicaid rates. Fee-for-service reimbursement rates
will be based on Medicaid fee-for-service physician rates. Federally Qualified Health
Centers will not receive prospective payment system rates.
Upon implementation of the automated system, up to 100% of the total award may be
reimbursed on a fee-for-service basis if the awardee so chooses.
Medicaid Provider Enrollment
DSHS PHC contractors must be enrolled as Medicaid (Title XIX) providers with the Texas
Medicaid & Healthcare Partnership (TMHP) in order to receive payment for PHC
services. PHC contractors must complete required Medicaid provider enrollment
application forms and enter into a written provider agreement with the Health and Human
Services Commission (HHSC), the single state Medicaid agency. TMHP Provider
Enrollment supplies these forms. Forms may be downloaded or potential respondents
may complete an online application on the TMHP website: http://www.tmhp.com.
Respondents proposing to subcontract all direct medical services may request a waiver
to this requirement. This waiver must be included on Form E, Exceptions.
Monthly Cost Reimbursement Process
To be reimbursed for expenses incurred through a cost reimbursement method,
contractors must develop a categorical budget, allocating DSHS approved costs to the
following categories, as identified during the contractor's budget development process.
Final budgets (including equipment purchases) must be approved by DSHS:
• Personnel
• Fringe Benefits
• Travel
• Equipment
• Supplies
Page 16 PHC RFP#537-16-142081
• Contractual
• Other
• Indirect Costs
Reimbursement for the cost reimbursement portion of the PHC award is requested by
using the State of Texas Purchase Voucher (DSHS Form B-13) and supporting
documentation to report costs and fees/co-pays/other party reimbursements collected
and received. DSHS Purchase Voucher (Form B-13) and back-up cost and revenue
reporting must be submitted monthly within 30 days following the end of the month in
which the costs were incurred.
Fee-For-Service Reimbursement Process
Upon implementation of the automated claim system described in Section 1, I.D. Use of
Funds, a percentage of funds (as determined by DSHS) will be used to reimburse
contractors on a fee-for-service basis for services and supplies that have been provided
to eligible clients. Reimbursement for these fee-for-service claims must be reported as
program income on the cost and revenue reporting form for the categorical portion of the
contract award.
After implementation of the automated claim system, PHC contractors must continue to
submit claims to the automated claim system for eligible client services during the entire
contract period regardless of whether or not the contract limit has been billed and
reimbursed. Claims data must be submitted using approved claim forms to be provided
before or upon implementation of the automated claim system.
Claims for unreimbursed services in excess of the contract amount may be considered in
any contract re-allocation process at the discretion of DSHS.
D. Schedule of Events
1. RFP Release Date 04/01/15
2. Proposal Conference 04/15/15
3. Deadline for Submitting Questions 04/17/15
4. HHSC Post Answers to Vendor Questions 04/23/15
5. Deadline for Submission of Proposals 04/30/15
6. Post Tentative Award Announcement 07/24/15
7. Post Final Award Announcement 09/01/15
8. Anticipated Contract Begin Date 09/01/15
HHSC reserves the right to change the dates shown above without notice. It is the
responsibility of the respondent to check the HHSC Business Opportunities website frequently
for notice of matters affecting the RFP. To access the website, go to
http://www.hhsc.state.tx.us/about hhsc/BusOpp/contract-opportunities.asp
Page 17 PHC RFP#537-16-142081
II. PROGRAM INFORMATION
A.General Purpose and Program Goals — Scope of Work
The purpose of the DSHS Primary Health Care (PHC) Program is to ensure
that low-income Texas residents whose gross income is at or below 200% of
Federal Poverty Level (FPL) and who are not eligible for similar services
through other non-DSHS programs or benefits, have access to preventive
and primary health services.
PHC Contractors shall deliver comprehensive health care services to eligible
low-income individuals as authorized under the Texas Health and Safety
Code, Chapter 31, Primary Health Care (PHC) Services Act. Contractor must
offer the following priority services: diagnosis and treatment; emergency
services; family planning services; preventive health services, including
immunizations; health education; and laboratory, x-ray, nuclear medicine or
other appropriate diagnostic services. In addition to priority services,
Contractor may provide one or more of the following optional PHC services:
nutrition services, health screening, home health care, dental care,
transportation, prescription drugs, environmental health, podiatry, and social
services.
Contractors shall develop and implement policies and procedures to ensure
that all clients complete an application for program services, and that
eligibility is determined according to the eligibility requirements as outlined in
25 TAC, §§ 39.1-39.11. Contractors shall ensure the quality of services by
monitoring performance and identifying opportunities for improvement.
The following performance measures will be used to assess, in part,
Contractor's effectiveness in providing the services described in the
applicable Program Attachment, without waiving the enforceability of any of
the other terms of the contract:
Number of unduplicated DSHS PHC clients to be provided services during
fiscal year (or contract period).
Contractor shall submit monthly, quarterly, and annual programmatic reports
and/or financial vouchers/reports as required in the PHC Policy Manual.
Other data and/or reports deemed necessary by DSHS may be required,
upon reasonable notice to Contractor.
B. Legal Authority
DSHS is authorized to enter into contracts through Texas Health and Safety Code,
Section 12.051. The Primary Health Care Services Act, HB 1844, was established
during the 69th Texas Legislature and is the statutory authority for Primary Health
Care Services administered by DSHS. The program operates under the Health and
Page 18 PHC RFP#537-16-142081
Safety Code, Chapter 31, and 25 Texas Administrative Code, Chapter 39,
Subchapter A.
C. Program Requirements
Contractors are required to conduct Project activities in accordance with federal and
state laws prohibiting discrimination. Guidance for adhering to non-discrimination
requirements can be found on the Health and Human Services Commission (HHSC)
Civil Rights Office website at:
http://www.hhs.state.tx.us/aboutHHS/CivilRights.shtml.
Upon request, a contractor must provide the HHSC Civil Rights Office with copies of
all the contractor's civil rights policies and procedures. Contractors must notify
HHSC's Civil Rights Office of any civil rights complaints received relating to
performance under the contract no more than 10 calendar days after receipt of the
complaint. Notice must be directed to:
HHSC Civil Rights Office
701 W. 51st Street, Mail Code W206
Austin, TX 78751
Phone Toll Free (888) 388-6332
Phone: (512) 438-4313
TTY Toll Free (877) 432-7232
Fax: (512) 438-5885
A contractor must ensure that its policies do not have the effect of excluding or
limiting the participation of persons in the contractor's programs, benefits or
activities on the basis of national origin, and must take reasonable steps to provide
services and information, both orally and in writing, in appropriate languages other
than English, in order to ensure that persons with limited English proficiency are
effectively informed and can have meaningful access to programs, benefits, and
activities.
Contractors must comply with Executive Order 13279, and its implementing
regulations at 45 CFR Part 87 or 7 CFR Part 16, which provide that any organization
that participates in programs funded by direct financial assistance from the U.S.
Dept. of Agriculture or U.S. Dept. of Health and Human Services must not, in
providing services, discriminate against a program beneficiary or prospective
program beneficiary on the basis of religion or religious belief.
Contractors are required to conduct Project activities in accordance with the most
recent DSHS Standards for Public Health Clinic Services and the most recent DSHS
PHC Policy Manual.
Contractors may obtain a copy of the most recent DSHS Standards for Public
Health Clinic Services which is posted on the DSHS website at:
http://www.dshs.state.tx.us/qmb/dshsstndrds4clinicservs.pdf.
Page 19 PHC RFP#537-16-142081
As detailed in the policy manual, PHC Program requirements include:
1. Client Eligibility Determination - Contractor must screen all
individuals for potential eligibility for other programs before determining
an individual's eligibility for PHC.
To be PHC eligible, a client must be:
• a Texas resident;
• at or below 200% of the current federal poverty level (FPL)
guidelines; and
• not eligible for other non-DSHS services or benefits that provide
the same services.
Information about client screening and eligibility is included in the PHC
Policy Manual.
2. Work Plan - If respondent is awarded a contract to provide PHC
services, the respondent's approved Work Plan (Form I) will be used
to assess the respondent's performance in providing and coordinating
the priority PHC services in the proposed service area. The
respondent must address:
• data collection;
• reporting activities; and
• quality assurance processes.
DSHS reserves the right to modify the Statement of Work of the contract and to
incorporate Special Provisions into contracts awarded under this RFP.
Page 20 PHC RFP#537-16-142081
III. PROCUREMENT REQUIREMENTS
A. RFP Point of Contact
For purposes of submitting questions concerning this RFP, the only contact is
Mahsa Azadi unless otherwise delegated by the PCS Manager. All
communications concerning this RFP must be submitted by email (preferred), mail,
hand-delivery, or fax to:
Mailing Address for Regular Mail:
Mahsa Azadi, Procurement Project Manager
Vonda White, CTPM
Ref: RFP# 537-16-142081
Procurement and Contracting Services Division MC 2020
Health and Human Services Commission
4405 N. Lamar
Austin, Texas 78756
Physical Address for Overnight Mail or hand-delivery:
Mahsa Azadi, Procurement Project Manager
Vonda White, CTPM
Ref: RFP# 537-16-142081
Procurement and Contracting Services Division MC 2020
Health and Human Services Commission
4405 N. Lamar
Austin, Texas 78756
Phone and Fax Numbers:
512/206-4785 phone
512/206-5552 fax
Email: mahsa.azadi@hhsc.state.tx.us
Other employees and representatives of HHSC or DSHS are not permitted to
answer questions or otherwise discuss the contents of the RFP with any
respondents or potential respondents or their representatives. Failure to observe
this restriction may result in disqualification of this or other subsequent proposals.
This restriction does not preclude discussions between affected parties for the
purpose of conducting business unrelated to this RFP.
Written inquiries or questions about this RFP must be received no later than the
date specified in Section I.D. Schedule of Events by 2:00 P.M. Central Time (CT).
Questions submitted after this date and time will not be answered. Questions will
not be answered verbally. Questions must be submitted by email (preferred), mail,
hand-delivery, or fax to the addresses or numbers above.
All questions and answers will be posted on the HHSC Business Opportunities
website at: http://www.hhsc.state.tx.us/about_hhsc/BusOpp/contract-
Page 21 PHC RFP#537-16-142081
opportunities.asp. Postings may be made as questions are answered; however, all
questions will be answered and posted no later than 5:00 P.M. CT on the date
specified in Section I D. Schedule of Events.
HHSC is the point of contact with regard to all procurement and contractual matters
relating to the services described herein prior to the award of any contract(s) as a
result of this RFP. HHSC is the only office authorized to clarify, modify, amend,
alter, or withdraw the Project requirements, terms, and conditions of this RFP.
B. Proposal Conference
HHSC will conduct a Proposal Conference on the date identified in Section I.D.
Schedule of Events from 1:30 P.M. - 4:30 P.M. CT located at HHSC, Building 2,
909 W. 45th Street, Austin, TX 78756, 2nd Floor, Conference Room 164.
Potential respondents also have the option to listen-in to the Proposal Conference
via teleconference. Call-in information: 1-877-226-9790. To access the
teleconference enter 2722551# to listen-in. Those respondents that plan to listen-in
must submit their questions prior to the Proposal Conference via email by 2:00 P.M.
(CT), April 14, 2015, to the designated RFP Point of Contact mailbox
(mahsa.azadi@hhsc.state.tx.us.) Questions will not be accepted over the phone
during the Proposal Conference.
The purpose of this conference will be to discuss the requirements of the RFP, work
to be performed under the contract, and address any other unanswered questions.
The conference is for information purposes only. Any answers furnished will not be
official until verified in writing by HHSC in the HHSC Business Opportunities website
at: http://www.hhsc.state.tx.us/about hhsc/BusOpp/contract-opportunities.asp.
Written questions may be submitted at the conference, and answers will be posted
to HHSC website. Refer to Section I.D. Schedule of Events for the deadline to
submit questions and the anticipated posting date of the answers on the HHSC
website.
HHSC strongly recommends, but does not require, attendance at the conference.
Attendees should bring their copy of this RFP to the conference as copies will not be
available for hand-outs. Any respondent considering subcontracting will benefit
from the information regarding HUB Subcontracting Plan instructions and reporting.
C. Proposal Due Date
The proposal must be received on or before the following date and time:
2:00 P.M. CT on the date specified in Section I. D. Schedule of Events.
D. Submission
Submit one (1) original, five (5) additional copies and one (1) copy on electronic
media; such as a flash drive or compact disc. Any disparities between the contents
of the original printed proposal and copies will be interpreted in favor of HHSC.
Page 22 PHC RFP#537-16-142081
Proposals must be submitted on or before the due date to the RFP point of
contact at the address specified in Section III. A. RFP Point of Contact. HHSC
will not accept proposals by fax or email.
If a proposal is sent by overnight mail or hand-delivered to the HHSC address
above, the respondent should request a receipt at the time of delivery to verify the
proposal was received on or before the proposal due date and time. Hand-
delivered proposals must be delivered to the room number identified in
Section III. A. RFP Point of Contact. This is the only official date and time stamp
accepted as verification of receipt.
If a proposal is mailed, it is considered as meeting the deadline if it is delivered to
the correct address as reflected in Section III. A. RFP Point of Contact and received
by HHSC on or before the due date and time.
Respondents sending proposals by the United States Postal Service or commercial
delivery services must ensure the carrier will be able to guarantee delivery of the
proposal by the due date and time. HHSC may make exceptions only for natural
disasters or catastrophes in the affected area as determined by HHSC. The
respondent must submit to the RFP contact proper documentation that reflects the
above exceptions before HHSC can consider the proposal as having been received
by the deadline. It is the respondent's responsibility to ensure timely delivery of the
proposal as required by this RFP.
Proposals that do not meet the above criteria will not be eligible for competition.
IV. PROPOSAL SCREENING AND EVALUATION
Proposals will be reviewed according to the criteria below. To maximize fairness for all
proposals during review, HHSC staff may only confirm receipt of a proposal and are not
permitted to discuss the proposal or its review during the review process. All proposals
remain with HHSC and will not be returned to the respondent.
A. Screening Process
Proposals are initially screened for eligibility and completeness. The preliminary
screening or eligibility criteria requirements include the following:
1. Proposal received on or before the proposal due date and time.
2. The original proposal bears an original signature of the authorized
official of the respondent organization on Form A. Face Page.
3. Historically Underutilized Business (HUB) subcontracting plan that
meets HUB requirements is included. Note to All Respondents:
Texas law provides that a proposal submitted in response to this
RFP that does not contain a HUB subcontracting plan is non-
responsive, in accordance with Texas Government Code §
2161.252.
Page 23 PHC RFP#537-16-142081
4. Form D: Administrative Information will be used in the initial screening
process. This information may be used to exclude a proposal from
review at the sole discretion of HHSC.
5. Respondent is prohibited from submitting more than one proposal in
response to this RFP.
6. Other preliminary screening criteria as needed and appropriate.
In conducting the screening process, HHSC at its sole discretion may give
respondents an opportunity to submit missing information or correct identified areas
of noncompliance within a specified period of time. In such an instance, if no new
information is received by the stated deadline, the proposal will be screened as is or
may be disqualified from the evaluation process. Information submitted after the
deadline will not be part of the evaluation.
HHSC reserves the right to waive irregularities that HHSC in its sole discretion
determines to be minor. If such irregularities are waived, similar irregularities in all
proposals will be waived.
PROPOSALS MAY BE EXCLUDED FROM REVIEW AND EVALUATION BASED
ON THE SCREENING PROCESS OR ADMINISTRATIVE INFORMATION
PROVIDED ON FORM D.
B. Evaluation Process
Proposals that successfully pass the initial screening will be evaluated by an
evaluation team consisting of DSHS Staff using the standard evaluation criteria as
outlined below. In addition, past performance may be used as evaluation criteria if
there are quantitative performance measures available. Consideration will be given
to contractors serving border or rural counties to access a greater percentage of
funds on a cost-reimbursement basis in order to maintain the infrastructure
necessary for the provision of services at adequate levels.
In the event an item of non-compliance appears in a significant number of
proposals, suggesting a possible lack of clarity in the RFP, HHSC at its sole
discretion, may give all respondents an opportunity to correct the identified areas of
noncompliance within a specified period of time. In such an instance, if no new
information is received by the stated deadline, the proposal will be evaluated as is.
Information submitted after the deadline will not be part of the evaluation.
Page 24 PHC RFP#537-16-142081
C. Evaluation Criteria
The proposal sections are as follows:
Pro•osal Corn•onents
FORM F: Respondent Background
FORM G: Assessment Narrative
FORM H: Performance Measures
FORM I: Work Plan
FORM K: Financial Management and Administration Questionnaire
FORM L: Clinic Site
FORM L-1: Clinic Site Readiness
APPENDIX A: Budget (All Forms)
D. Selection, Negotiation, and Award
Funding awards will be based on respondent scores, available funds, respondent
scores, respondent readiness, cost per client as relevant to the proposed Statement
of Work, demonstration by the respondent of the ability to provide services to a
population in need as described in the Assessment Narrative (Form G) and the
Work Plan (Form I), ensuring appropriate statewide coverage, and considering the
best interest of the State in providing services under this RFP.
The specific dollar amount awarded to each successful respondent will depend
upon the merit and scope of the proposal and other best value considerations. Not
all respondents who are deemed eligible to receive funds are assured of receiving
an award.
The final funding amount and the provisions of the contract will be determined at the
sole discretion of DSHS staff.
Any exceptions to the requirements, terms, conditions, or certifications in the
RFP or attachments, addendums, or revisions to the RFP or General
Provisions, sought by the respondent must be specifically detailed in writing
by the respondent on Form E: Exception Form in this proposal and submitted
to DSHS for consideration. DSHS will accept or reject each proposed
exception. DSHS will not consider exceptions submitted separately from the
respondent's proposal or at a later date.
Page 25 PHC RFP#537-16-142081
HHSC will post to the HHSC Business Opportunities Website a list of respondents
whose proposals are selected for tentative award. This posting does not constitute
DSHS's agreement with all the terms of any respondent's proposal and does not
bind DSHS to enter into a contract with any respondent whose tentative award is
posted.
HHSC will post to the HHSC Business Opportunities Website a list of respondents
whose proposals are selected for final award after negotiation.
V. HHSC ADMINISTRATIVE INFORMATION
A. Rejection of Proposals
1. HHSC reserves the right to reject any or all proposals and is not liable
for any costs incurred by the respondent in the development or
submission of the proposal.
2. Any attempt by an employee, officer, or agent of the respondent to
influence the outcome of HHSC's review through contact with any
Commissioner or staff member of HHSC or other Texas Health and
Human Services agency will result in rejection of the proposal.
3. Any material misrepresentation in a proposal submitted to HHSC will
result in rejection of the proposal.
4. Form D: Administrative Information. Information supplied on this form
will be used in the screening, evaluation, and/or rejection of any
proposal.
5. Proposals may be rejected for failure to meet screening criteria or
respondent eligibility criteria.
B. Right to Amend or Withdraw RFP
HHSC reserves the rights to alter, amend, or modify any provisions of this RFP or to
withdraw this RFP at any time prior to the execution of a contract if it is in the best
interest of DSHS and the State of Texas. The decision of HHSC is administratively
final. Amendment or notice of withdrawal of the RFP will be posted to the HHSC
Business Opportunities website. It is the sole responsibility of the respondent to
check the HHSC Business Opportunities website throughout the RFP process for
changes and/or updates to this RFP.
C. Authority to Bind DSHS
For the purposes of this RFP, the only individuals who may legally commit DSHS to
the expenditure of public funds under the contract are the Executive Commissioner,
Commissioner of DSHS, Assistant Commissioner, Chief Financial Officer, Chief
Operating Officer, or the employee designated to act in place of one of those
employees through commissioner's directive relating to line of authority, CD-
2005.02. No costs chargeable to the proposed contract will be reimbursed before
the contract is fully executed.
Page 26 PHC RFP#537-16-142081
D. Financial and Administrative Requirements
General Provisions
1. All contractors under this RFP must comply with the DSHS General
Provisions posted on the HHSC Business Opportunities website with this
RFP. The General Provisions are also located at:
http://www.dshs.state.tx.us/grants/gen-prov.shtm.
Respondent is not required to return the General Provisions or DSHS
Assurances and Certifications with its proposal. By signing the Form A: Face
Page, respondent is agreeing to abide by the referenced General Provisions
and DSHS Assurances and Certifications.
2. All contractors under this solicitation must comply with applicable cost
principles, audit requirements, and administrative requirements. Form K.
Financial Management and Administrative Questionnaire is required.
By accepting an award from the Department of State Health Services (DSHS) your
organization and the Board of Directors or other oversight authority accept
responsibility for complying with the management and administration of
programmatic, financial and reporting requirements of the award. Communication
and coordination between the organization's program implementation and financial
staff is essential for the success of the project being funded by the award. It is
critical that staff responsible for the programmatic and accounting functions is
aware of the financial and administrative requirements applicable to grants and
subgrants. Key personnel within the organization should be identified and assigned
responsibilities for the programmatic, financial and administrative requirements
applicable to the DSHS award.
All DSHS contractors are required to maintain a financial management system that
meets federal and state standards for expending and accounting for funds received
under an award. Documents and records must be maintained that identify the
receipt and expenditure of funds separately for each DSHS contract and/or
program attachment and will record expenditures by the budget cost categories in
the approved budget for a cost reimbursement program attachment. This requires
establishing within the chart of accounts and general ledger, a separate set of
accounts for each program attachment. All financial reports should be prepared
with information that comes directly from the organization's accounting system.
There should be a reconciliation of the information that is reported to amounts
recorded in the accounting system.
Additional requirements on basic accounting and financial management systems
are found in DSHS General Provisions, Allowable Costs and Audit Requirements
and the DSHS Contractor Financial Procedures Manual. Copies of the procedures
Page 27 PHC RFP#537-16-142081
manual are available online at http://www.dshs.state.tx.us/contracts/cfpm.shtm.
OMB Circulars may be found at http//www.whitehouse.gov/omb/circulars. Internet
links to laws and regulations applicable to the financial and administrative
requirements of grants and sub grants are provided below.
Circulars (CFRs):http://www.whitehouse.gov/omb/grants/grants_circulars.html
Federal agency common rules: http://www.whitehouse.gov/omb/grants/chart.html
Code of Federal Regulations: http://www.access.gpo.gov/nara/cfr/cfr-table-
search.html
Uniform Grant Management Standards:
http://governor.state.tx.us/files/state-grants/UGMS062004.doc
Federal Department of Health and Human Services, Grants Policy Statement:
http://www.hhs.gov/grantsnet/adminis/gpd/
E. Contracting with Subcontractors
The selected contractor may enter into contracts with subrecipient subcontractors
unless restricted or otherwise prohibited in a specific Program Attachment(s). Prior
to entering into an agreement equaling or exceeding $100,000, Contractor shall
obtain written approval from DSHS. The contractor is responsible to DSHS for the
performance of any subcontractor or sub-grantee.
If the selected respondent enters into contracts with vendor or subrecipient
subcontractors, the documents must be in writing and must comply with the
requirements specified in articles of the General Provisions posted on the HHSC
Business Opportunities website in conjunction with this RFP.
F. Historically Utilized Business Participation
In accordance with Texas Government Code §2161.252, a proposal that does not
contain a HUB Subcontracting Plan (HSP) is non-responsive and will be rejected
without further evaluation. In addition, if HHSC determines that the HSP was not
developed in good faith, it will reject the proposal for failing to comply with material
RFP specifications.
1. Introduction
HHSC is committed to promoting full and equal business opportunities for businesses in state
contracting in accordance with the goals specified in the State of Texas Disparity Study.
HHSC encourages the use of Historically Underutilized Businesses (HUBs) through race,
ethnic and gender-neutral means. HHSC has adopted administrative rules relating to HUBs
and a Policy on the Utilization of HUBs which is located on HHSC's website.
Page 28 PHC RFP#537-16-142081
Pursuant to Texas Government Code §2161.181 and §2161.182 and HHSC's HUB policy and
rules, HHSC is required to make a good faith effort to increase HUB participation in its
contracts. HHSC may accomplish the goal of increased HUB participation by contracting
directly with HUBs or indirectly through subcontracting opportunities.
2. HHSC's Administrative Rules
HHSC has adopted the CPA's HUB rules as its own. HHSC's rules are located in the Texas
Administrative Code Title 1, Part 15, Chapter 392, Subchapter J and the CPA rules are
located in Texas Administrative Code Title 34, Part 1, Chapter 20, Subchapter B. If there are
any discrepancies between HHSC's administrative rules and this RFP, the rules shall take
priority.
3. Statewide Annual HUB Utilization Goal
The CPA has established statewide annual HUB utilization goals for different categories of
contracts in Texas Administrative Code Title 34, Part 1, Chapter 20, Subchapter B, §20.13 of
the HUB rules. In order to meet or exceed the statewide annual HUB utilization goals,
HHSC encourages outreach to certified HUBs. Contractors shall make a good faith effort to
include certified HUBs in the procurement process.
This procurement is classified as an Other Services procurement under the CPA rule and
therefore has a statewide annual HUB utilization goal of 26.0% per fiscal year.
4. Required HUB Subcontracting Plan
In accordance with Texas Government Code Chapter 2161, Subchapter F, §2161.252 each
state agency that considers entering into a contract with an expected value of $100,000 or
more over the life of the contract (including any renewals) shall, before the agency solicits
bids, proposals, offers, or other applicable expressions of interest, determine whether
subcontracting opportunities are probable under the contract.
In accordance with Texas Administrative Code Title 34, Part 1, Chapter 20, Subchapter B,
§20.14(a)(1)(C) of the HUB Rule, state agencies may determine that subcontracting is
probable for only a subset of the work expected to be performed or the funds to be expended
under the contract. If an agency determines that subcontracting is probable on only a portion
of a contract, it shall document its reasons in writing for the procurement file.
HHSC has determined that subcontracting opportunities are probable for this RFP. As a result,
the respondent must submit an HSP with its proposal. The HSP is required whether a
respondent intends to subcontract or not.
In the HSP, a respondent must indicate whether it is a Texas certified HUB. Being a certified
HUB does not exempt a respondent from completing the HSP requirement.
HHSC shall review the documentation submitted by the respondent to determine if a good
faith effort has been made in accordance with solicitation and HSP requirements. During the
Page 29 PHC RFP#537-16-142081
good faith effort evaluation, HHSC may, at its discretion, allow revisions necessary to clarify
and enhance information submitted in the original HSP.
If HHSC determines that the respondent's HSP was not developed in good faith, the HSP will
be considered non-responsive and will be rejected as a material failure to comply with
advertised specifications. The reasons for rejection shall be recorded in the procurement file.
5. CPA Centralized Master Bidders List
Respondents may search for HUB subcontractors in the CPA's Centralized Master Bidders
List (CMBL) HUB Directory, which is located on the CPA's website at
http://www2.cpa.state.tx.us/cmbl/cmblhub.html. For this procurement, HHSC has identified
the following class and item codes for potential subcontracting opportunities:
NIGP Class/Item Code:
• 193-66 Nuclear Test Kits
• 260-82 Dental Care Kits
• 948-27 Dental Laboratory Services
• 948-28 Dental Services
• 948-32 Nutrition Development Services
• 948-47 Health Care Center Services
• 948-48 Health Care Services (Not Otherwise Classified)
• 948-97 Dental X-Ray Services
• 952-42 Family Planning Services
• 952-43 Family and Social Services
• 952-88 Teenage Pregnancy Services
• 952-90 Training and Instruction (for Clients, Not Staff)
• 952-94 Transportation Services for Elderly, Handicapped, etc
• 958-56 Health Care Management Services
• 961-48 Laboratory Testing Services
Respondents are not required to use, nor limited to using, the class and item codes identified
above, and may identify other areas for subcontracting.
HHSC does not endorse, recommend nor attest to the capabilities of any company or
individual listed on the CPA's CMBL. The list of certified HUBs is subject to change, so
respondents are encouraged to refer to the CMBL often to find the most current listing of
HUBs.
6. HUB Subcontracting Procedures — If a Respondent Intends to Subcontract
An HSP must demonstrate that the respondent made a good faith effort to comply with
HHSC's HUB policies and procedures. The following subparts outline the items that HHSC will
review in determining whether an HSP meets the good faith effort standard. A respondent that
intends to subcontract must complete the HSP to document its good faith efforts.
For step-by-step audio/video instructions on how to complete the HSP, you may also visit the
Page 30 PHC RFP#537-16-142081
CPA's website at: http://www.cpa.state.tx.us/procurement/prog/hub/hub-subcontracting-plan
6.1 Identify Subcontracting Areas and Divide Them into Reasonable Lots
A respondent should first identify each area of the contract work it intends to
subcontract. Then, to maximize HUB participation, it should divide the contract work
into reasonable lots or portions, to the extent consistent with prudent industry practices.
6.2 Notify Potential HUB Subcontractors
The HSP must demonstrate that the respondent made a good faith effort to subcontract
with HUBs. The respondent's good faith efforts shall be shown through utilization of all
methods in conformance with the development and submission of the HSP and by
complying with the following steps:
6.2.1. Divide the contract work into reasonable lots or portions to the extent
consistent with prudent industry practices. The respondent must determine
which portions of work, including goods and services, will be subcontracted.
6.2.2. Use the appropriate method(s) to demonstrate good faith effort. The
respondent can use either method(s) 1, 2, 3, or 4:
6.3 Method 1: Respondent Intends to Subcontract with only HUBs:
The respondent must identify in the HSP the HUBs that will be utilized and submit
written documentation that confirms 100% of all available subcontracting opportunities
will be performed by one or more HUBs; or,
6.4 Method 2: Respondent Intends to Subcontract with HUB Protege(s):
The respondent must identify in the HSP the HUB protege(s) that will be utilized and
should:
• Include a fully executed copy of the Mentor Protégé Agreement, which must be
registered with the CPA prior to submission to HHSC; and
• Identify areas of the HSP that will be performed by the protégé
HHSC will accept a Mentor Protégé Agreement that has been entered into by a
respondent (Mentor) and a certified HUB (Protégé) in accordance with Texas
Government Code §2161.065. When a respondent proposes to subcontract with a
Protege(s), it does not need to provide notice to three (3) HUB vendors for that
subcontracted area.
Participation in the Mentor Protégé Program, along with the submission of a Protégé as
a subcontractor in an HSP, constitutes a good faith effort for the particular area
subcontracted to the protégé; or,
6.5 Method 3: Respondent Intends to Subcontract with HUBs and Non-HUBs
(Meet or Exceed the Goal):
Page 31 PHC RFP#537-16-142081
The respondent must identify in the HSP and submit written documentation that one or
more HUB subcontractors will be utilized; and that the aggregate expected percentage
of subcontracts with HUBs will meet or exceed the goal specified in this solicitation.
When utilizing this method, only HUB subcontractors that has existing contracts with
the respondent for five years or less may be used to comply with the good faith effort
requirements.
When the aggregate expected percentage of subcontracts with HUBs meets or
exceeds the goal specified in this solicitation, respondents may also use non-HUB
subcontractors; or,
6.6 Method 4: Respondent Intends to Subcontract with HUBs and Non-HUBs
(Does Not Meet or Exceed the Goal):
The respondent must identify in the HSP and submit documentation regarding both of
the following requirements:
• Written notification to minority or women trade organizations or development
centers to assist in identifying potential HUBs of the subcontracting opportunities the
respondent intends to subcontract.
Respondents must give minority or women trade organizations or development
centers at least seven (7) working days prior to submission of the respondent's
response for dissemination of the subcontracting opportunities to their members. A
list of minority and women trade organizations is located on HHSC's website under
the Minority and Women Organization link.
• Written notification to at least three (3) HUB businesses of the subcontracting
opportunities that the respondent intends to subcontract. The written notice must be
sent to potential HUB subcontractors prior to submitting proposals and must include:
• a description of the scope of work to be subcontracted;
• information regarding the location to review project plans or specifications;
• information about bonding and insurance requirements;
• required qualifications and other contract requirements; and
• a description of how the subcontractor can contact the respondent.
Respondents must give potential HUB subcontractors a reasonable amount of time to
respond to the notice, at least seven (7) working days prior to submission of the
respondent's response unless circumstances require a different time period, which is
determined by the agency and documented in the contract file;
Respondents must also use the CMBL, the HUB Directory, and Internet resources
when searching for HUB subcontractors. Respondents may rely on the services of
contractor groups; local, state and federal business assistance offices; and other
organizations that provide assistance in identifying qualified respondents for the HUB
program.
Page 32 PHC RFP#537-16-142081
Written Justification of the Selection Process
HHSC will make a determination if a good faith effort was made by the respondent in
the development of the required HSP. One or more of the methods identified in the
previous sections may be applicable to the respondent's good faith efforts in developing
and submission of the HSP. HHSC may require the respondent to submit additional
documentation explaining how the respondent made a good faith effort in accordance
with the solicitation.
A respondent must provide written justification of its selection process if it chooses a
non-HUB subcontractor. The justification should demonstrate that the respondent
negotiated in good faith with qualified HUB bidders, and did not reject qualified HUBs
who were the best value responsive bidders.
6.7 Method 5: Respondent Does Not Intend to Subcontract
When the respondent plans to complete all contract requirements with its own
equipment, supplies, materials and/or employees, it is still required to complete an
HSP.
The respondent must complete the "Self Performance Justification" portion of the HSP,
and attest that it does not intend to subcontract for any goods or services, including the
class and item codes identified in Section 4.5. In addition, the respondent must identify
the sections of the proposal that describe how it will complete the Scope of Work using
its own resources or provide a statement explaining how it will complete the Scope of
Work using its own resources. The respondent must agree to comply with the following
if requested by HHSC:
• provide evidence of sufficient respondent staffing to meet the RFP requirements;
• provide monthly payroll records showing the respondent staff fully dedicated to the
contract;
• allow DSHS to conduct an on-site review of company headquarters or work site
where services are to be performed and,
• provide documentation proving employment of qualified personnel holding the
necessary licenses and certificates required to perform the Scope of Work.
7. Post-award HSP Requirements
The HSP shall be reviewed and evaluated prior to contract award and, if accepted, the
finalized HSP will become part of the contract with the successful respondent(s).
After contract award, HHSC will coordinate a post-award meeting with the successful
respondent to discuss HSP reporting requirements. The contractor must maintain
business records documenting compliance with the HSP, and must submit monthly
subcontract reports to DSHS by completing the HUB Prime Contractor Progress
Assessment Report. This monthly report is required as a condition for payment to
report to the agency the identity and the amount paid to all subcontractors.
Page 33 PHC RFP#537-16-142081
As a condition of award the Contractor is required to send notification to all selected
subcontractors as identified in the accepted/approved HSP. In addition, a copy of the
notification must be provided to the agency's Contract Manager and/or HUB Program
Office within 10 days of the contract award.
During the term of the contract, if the parties in the contract amend the contract to
include a change to the scope of work or add additional funding, HHSC will evaluate to
determine the probability of additional subcontracting opportunities. When applicable,
the Contractor must submit an HSP change request for HHSC review. The
requirements for an HSP change request will be covered in the post-award meeting.
When making a change to an HSP, the Contractor will obtain prior written approval from
HHSC before making any changes to the HSP. Proposed changes must comply with
the HUB Program good faith effort requirements relating to the development and
submission of a HSP.
If the Contractor decides to subcontract any part of the contract after the award, it must
follow the good faith effort procedures outlined in Section 4.6 of this RFP (e.g., divide
work into reasonable lots, notify at least three (3) vendors per subcontracted area,
provide written justification of the selection process, and/or participate in the Mentor
Protégé Program).
For this reason, HHSC encourages respondents to identify, as part of their HSP,
multiple subcontractors who are able to perform the work in each area the respondent
plans to subcontract. Selecting additional subcontractors may help the selected
contractor make changes to its original HSP, when needed, and will allow HHSC to
approve any necessary changes expeditiously.
Failure to meet the HSP and post-award requirements will constitute a breach of
contract and will be subject to remedial actions. HHSC may also report noncompliance
to the CPA in accordance with the provisions of the Vendor Performance and
Debarment Program.
G. Contract Information
DSHS will monitor contractors' expenditures. A contractor's budget may be subject
to a decrease for the remainder of the budget period if expenditure percentages are
below the amount projected and determined by DSHS. Vacant positions existing
after ninety (90) days may result in a decrease in funds. DSHS reserves the right to
adjust the funding allocation to contractors pursuant to the terms of the contract.
H. Contract Award Protest Procedures
Texas Administrative Code, Title 1, Part 15, Chapter 392, Subchapter C outlines HHSC's
respondent protest procedures.
Page 34 PHC RFP#537-16-142081
CONTENT AND PREPARATION
VI. PROPOSAL CONTENT
A. Instructions for Preparation
The proposal must be developed and submitted in accordance with the instructions
outlined in this section. The proposal should meet the following stylistic requirements:
• All pages clearly and consecutively numbered;
• One (1) original and five (5) additional copies, unbound, but secured
with binder clips or rubber bands;
• One (1) copy on electronic media (compact disc or flash drive) must be
included;
• Typed (computer or typewriter);
• No less than single-spaced;
• No less thanl2-point font on 8 1/2" x 11" paper with 1" margins;
• Black print on white paper;
• Blank forms provided in SECTION VII. BLANK FORMS AND
INSTRUCTIONS must be used (electronic reproduction of the forms is
acceptable; however, all forms must be identical to the original form(s)
provided); do not change the font used on forms provided.
• Signed in ink by an authorized official (copies must be signed but need
not bear an original signature);
• Envelope/package containing the proposal must clearly identify the
respondent's legal name and mailing address as reflected on Form A:
Face Page.
• Envelope/package containing the proposal must clearly identify the
name and number of the RFP as reflected on the cover page of this
RFP.
Specific instructions for each required section are provided. Instructions for
completing forms are found on each form.
B. Confidential Information
The respondent must clearly designate any portion(s) of this proposal that contains
confidential information and state the reasons the information should be designated
as such. Marking the entire proposal as confidential will be neither accepted
nor honored. If any information is marked as confidential in the proposal, DSHS will
determine whether the requested information may be exempted from disclosure
under the Public Information Act, Texas Government Code, Chapter 552. If it
constitutes an exception, and if a request is made by any other entity or individual
for the information marked as confidential, the information will be forwarded to the
Texas Attorney General along with a request for a ruling on its confidentiality.
Respondents are advised to consult with their legal counsel regarding disclosure
Page 35 PHC RFP#537-16-142081
issues and to take the appropriate precautions to safeguard trade secrets or any
other confidential information. Following the award of any contract, proposals to this
RFP are subject to release as public information unless any proposal or specific
parts of any proposal can be shown to be exempt from disclosure under the Public
Information Act, Texas Government Code, Chapter 552.
C. Table of Contents
THE PROPOSAL SHOULD INCLUDE A TABLE OF CONTENTS AND BE
ORGANIZED AND ARRANGED IN THE FOLLOWING ORDER:
Form A. Face Page - Proposal for Financial Assistance
Form A-1. Texas Counties and Regions
Form B. Proposal Table of Contents and Checklist
Form C. Contact Person Information
Form D. Administrative Information — attach required information
Form E. Exceptions Form
Form F. Respondent Background
Form G. Assessment Narrative
Form H. Performance Measures
Form H-1. Performance Measures Request for Exception
Form I. Work Plan
Form J. Child Support Certification
Form K. Financial Management and Administration Questionnaire
Form L. Clinic Site Forms
Form L-1. Clinic Site Readiness Forms
Appendix A. Budget — Budget Section forms and instructions are posted
separately on the HHSC Business Opportunities website.
Appendix B. DSHS Assurances and Certifications
Appendix C. HUB Subcontracting Plan
Page 36 PHC RFP#537-16-142081
VII. BLANK FORMS AND INSTRUCTIONS
Page 37 PHC RFP#537-16-142081
N * ' I E_x;�s Department of State Health Services
r . �
p I 1 ., FORM A: FACE PAGE
Primary Health Care Proposal for Financial Assistance(RFP#537-16-1420811
This form requests basic information about the respondent and project,including the signature of the authorized representative. The face page is the
cover page of the proposal and must be completed in its entirety.
RESPONDENT INFORMATION
1) LEGAL BUSINESS NAME:
2) MAILING Address Information(include mailing address,street,city,county,state and zip code): Check if address change ❑
3) PAYEE Name and Mailing Address(if different from above): Check if address change ❑
4) Federal Tax ID No.(9 digit),State of Texas Comptroller Vendor ID No.(14 digit)or Social Security
Number(9 digit):
*The respondent acknowledges,understands and agrees that the respondent's choice to use a social security number as the vendor identification
number for the contract,may result in the social security number being made public via state open records requests.
5)Medicaid Provider Number: OR Date Medicaid Application Submitted&TMHP Ticket#:
6)DUNS Number:
7) TYPE OF ENTITY(check all that apply):
❑ City ❑ Nonprofit Organization* ❑ Individual
❑ County ❑ For Profit Organization* ❑ FQHC
❑ Other Political Subdivision ❑ HUB Certified ❑ State Controlled Institution of Higher Learning
❑ State Agency ❑ Community-Based Organization ❑ Hospital
❑ Indian Tribe ❑ Minority Organization ❑ Private
❑ Faith Based(Nonprofit Org) ❑ Other(specify):
*If incorporated,provide 10-digit charter number assigned by Secretary of State:
8) PROPOSED BUDGET PERIOD: Start Date: End Date:
9) COUNTIES SERVED BY PROJECT: See attached list.Include completed Form A-1 behind Form A: Face Page.
10) TOTAL AMOUNT OF FUNDING
REQUESTED $ 12 PHC PROJECT CONTACT PERSON
11) PROJECTED EXPENDITURES $ Name:
Phone:
Does respondent's projected state or federal expenditures exceed$500,000 for Fax.
Email:
respondent's current fiscal year(excluding amount requested in line 9 above)?**
13) FINANCIAL OFFICER
Yes ❑ No ❑ Name:
Phone:
**Projected expenditures should include funding for all activities including'pass through' Fax:
federal funds from all state agencies and non project-related DSHS funds. E-mail:
The facts affirmed by me in this proposal are truthful and I warrant the respondent is in compliance with the assurances and certifications contained in APPENDIX B:
DSHS Assurances and Certifications. I understand the truthfulness of the facts affirmed herein and the continuing compliance with these requirements are
conditions precedent to the award of a contract. This document has been duly authorized by the governing body of the respondent and I(the person signing below)
am authorized to represent the respondent.
14)AUTHORIZED REPRESENTATIVE Check if change 0 15) SIGNATURE OF AUTHORIZED REPRESENTATIVE
Name:
Title:
Phone: 16) DATE
Fax:
E-mail:
Page 38 PHC RFP#537-1 6-1 42081
FORM A: FACE PAGE INSTRUCTIONS
This form provides basic information about the respondent and the proposed project with the Department of State Health Services(DSHS),including the signature of the
authorized representative.It is the cover page of the proposal and is required to be completed. Signature affirms the facts contained in the respondent's response are
truthful and the respondent is in compliance with the assurances and certifications contained in APPENDIX B:DSHS Assurances and Certifications and acknowledges
that continued compliance is a condition for the award of a contract. Please follow the instructions below to complete the face page form and return with the respondent's
proposal.
1. LEGAL BUSINESS NAME-Enter the legal business name of the respondent.
2. MAILING ADDRESS INFORMATION-Enter the respondent's complete physical address and mailing address,city,county,state,
and zip code.
3. PAYEE NAME AND MAILING ADDRESS-Payee—Entity involved in a contractual relationship with respondent to receive
payment for services rendered by respondent and to maintain the accounting records for the contract;i.e.,fiscal agent.Enter the
PAYEE's name and mailing address if PAYEE is different from the respondent. The PAYEE is the corporation,entity or vendor who
will be receiving payments.
4. FEDERAL TAX ID/STATE OF TEXAS COMPTROLLER VENDOR ID/SOCIAL SECURITY NUMBER-Enter the Federal Tax
Identification Number(9-digit)or the Vendor Identification Number assigned by the Texas State Comptroller(14-digit). *The
respondent acknowledges,understands and agrees the respondent's choice to use a social security number as the
vendor identification number for the contract may result in the social security number being made public via state open
records requests.
5. MEDICAID PROVIDER NUMBER OR DATE MEDICAID APPLICATION SUBMITTED—Enter the Medicaid provider number used
by the organization to bill Medicaid. If organization does not have a Medicaid number,enter the date an application was submitted
to obtain a Medicaid number and TMPH Ticket#. Attach a copy of the TMHP Ticket receipt. Medicaid enrollment is required for
eligibility for this procurement.
6. DUNS—Enter the identification number of respondent organization. If respondent organization does not have a DUNS number,
one can be requested at: http://fedqov.dnb.com/webform
7. TYPE OF ENTITY-The type of entity is defined by the Secretary of State and/or the Texas State Comptroller. Check all
appropriate boxes that apply.
HUB is defined as a corporation,sole proprietorship,or joint venture formed for the purpose of making a profit in which at least 51%
of all classes of the shares of stock or other equitable securities are owned by one or more persons who have been historically
underutilized(economically disadvantaged)because of their identification as members of certain groups: Black American, Hispanic
American,Asian Pacific American,Native American,and Women. The HUB must be certified by the Comptroller's Texas
Procurement and Support Services or another entity. MINORITY ORGANIZATION is defined as an organization in which the Board
of Directors is made up of 50%racial or ethnic minority members. If a Non-Profit Corporation or For-Profit Corporation,provide the
10-digit charter number assigned by the Secretary of State.
8. PROPOSED BUDGET PERIOD-Enter the budget period for this proposal. Budget period is defined in the RFP.
9. COUNTIES SERVED BY PROJECT—On line 9,write"See attached list." From the list on Form A-1: Texas Counties and
Regions,check the counties where medical services will be provided for proposed PHC Project and for which funds are requested.
Include with proposal behind Form A: Face Page.
10. AMOUNT OF FUNDING REQUESTED-Enter the amount of PHC funding requested from DSHS by type;total.
11. PROJECTED EXPENDITURES-If respondent's projected state or federal expenditures exceed$500,000 for respondent's current
fiscal year,respondent must arrange for a financial compliance audit(Single Audit).
12. PHC PROJECT CONTACT PERSON-Enter the name,phone,fax,and e-mail address of the person responsible for the proposed
PHC project.
13. FINANCIAL OFFICER-Enter the name,phone,fax,and e-mail address of the person responsible for the financial aspects of the
proposed project.
14. AUTHORIZED REPRESENTATIVE-Enter the name,title,phone,fax,and e-mail address of the person authorized to represent
the respondent. Check the"Check if change"box if the authorized representative is different from previous submission to DS HS.
15. SIGNATURE OF AUTHORIZED REPRESENTATIVE—The person authorized to represent the respondent must sign in this blank.
16. DATE-Enter the date the authorized representative signed this form.
Page 39 PHC RFP#537-16-142081
FORM A-1: TEXAS COUNTIES AND REGIONS LIST
in alphabetical order
Legal Business Name of
Respondent:
COUNTIES SERVED BY PROJECT-Item 9 of Form A:Face Page:Check®counties to be served and include behind Form A.Face Page.
Page 40 PHC RFP#537-16-142081
Counties ® R Counties ® R Counties ® R Counties ® R Counties ® R
-A- Crosby 0 01 Hays 0 07 Martin 0 09 Schleicher 0 09
Anderson 0 04 Culberson 0 10 Hemphill 0 01 Mason 0 09 Scurry 0 02
Andrews 0 09 -D- Henderson 0 04 Matagorda 0 06 Shackelford 0 02
Angelina 0 05 Dallam 0 01 Hidalgo 0 11 Maverick 0 08 Shelby 0 05
Aransas 0 11 Dallas 0 03 Hill 0 07 McCulloch 0 09 Sherman 0 01
Archer 0 02 Dawson 0 09 Hockley 0 01 McLennan 0 07 Smith 0 04
Armstrong 0 01 Deaf Smith 0 01 Hood 0 03 McMullen 0 11 Somervell 0 03
Atascosa 0 08 Delta 0 04 Hopkins 0 04 Medina 0 08 Starr 0 11
Austin 0 06 Denton 0 03 Houston 0 05 Menard 0 09 Stephens 0 02
-B- DeWitt 0 08 Howard 0 09 Midland 0 09 Sterling 0 09
Bailey 0 01 Dickens 0 01 Hudspeth 0 10 Milam 0 07 Stonewall 0 02
Bandera 0 08 Dimmit 0 08 Hunt 0 03 Mills 0 07 Sutton 0 09
Bastrop 0 07 Donley 0 01 Hutchinson 0 01 Mitchell 0 02 Swisher 0 01
Baylor 0 02 Duval 0 11 -I- Montague 0 02 -T-
Bee 0 11 -E- Irion 0 09 Montgomery 0 06 Tarrant 0 03
Bell 0 07 Eastland 0 02 -J- Moore 0 01 Taylor 0 02
Bexar 0 08 Ector 0 09 Jack 0 02 Morris 0 04 Terrell 0 09
Blanco 0 07 Edwards 0 08 Jackson 0 08 Motley 0 01 Terry 0 01
Borden 0 09 Ellis 0 03 Jasper 0 05 -N- Throckmorton 0 02
Bosque 0 07 El Paso 0 10 Jeff Davis 0 10 Nacogdoches 0 05 Titus 0 04
Bowie 0 04 Erath 0 03 Jefferson 0 05 Navarro 0 03 Tom Green 0 09
Brazoria 0 06 -F- Jim Hogg 0 11 Newton 0 05 Travis 0 07
Brazos 0 07 Falls 0 07 Jim Wells 0 11 Nolan 0 02 Trinity 0 05
Brewster 0 10 Fannin 0 03 Johnson 0 03 Nueces 0 11 Tyler 0 05
Briscoe 0 01 Fayette 0 07 Jones 0 02 -0- -U-
Brooks 0 11 Fisher 0 02 -K- Ochiltree 0 01 Upshur 0 04
Brown 0 02 Floyd 0 01 Karnes 0 08 Oldham 0 01 Upton 0 09
Burleson 0 07 Foard 0 02 Kaufman 0 03 Orange 0 05 Uvalde 0 08
Burnet 0 07 Fort Bend 0 06 Kendall 0 08 -P- -V-
-C- Franklin 0 04 Kenedy 0 11 Palo Pinto 0 03 Val Verde 0 08
Caldwell 0 07 Freestone 0 07 Kent 0 02 Panola 0 04 Van Zandt 0 04
Calhoun 0 08 Frio 0 08 Kerr 0 08 Parker 0 03 Victoria 0 08
Callahan 0 02 -G- Kimble 0 09 Parmer 0 01 -W-
Cameron 0 11 Gaines 0 09 King 0 01 Pecos 0 09 Walker 0 06
Camp 0 04 Galveston 0 06 Kinney 0 08 Polk 0 05 Waller 0 06
Carson 0 01 Garza 0 01 Kleberg 0 11 Potter 0 01 Ward 0 09
Cass 0 04 Gillespie 0 08 Knox 0 02 Presidio 0 10 Washington 0 07
Castro 0 01 Glasscock 0 09 -L- -R- Webb 0 11
Chambers 0 06 Goliad 0 08 Lamar 0 04 Rains 0 04 Wharton 0 06
Cherokee 0 04 Gonzales 0 08 Lamb 0 01 Randall 0 01 Wheeler 0 01
Childress 0 01 Gray 0 01 Lampasas 0 07 Reagan 0 09 Wichita 0 02
Clay 0 02 Grayson 0 03 La Salle 0 08 Real 0 08 Wilbarger 0 02
Cochran 0 01 Gregg 0 04 Lavaca 0 08 Red River 0 04 Willacy 0 11
Coke 0 09 Grimes ❑ 07 Lee 0 07 Reeves 0 09 Williamson 0 07
Coleman 0 02 Guadalupe ❑ 08 Leon 0 07 Refugio 0 11 Wilson 0 08
Collin 0 03 -H- Liberty 0 06 Roberts 0 01 Winkler 0 09
Collingsworth 0 01 Hale 0 01 Limestone 0 07 Robertson 0 07 Wise 0 03
Colorado 0 06 Hall 0 01 Lipscomb ❑ 01 Rockwall 0 03 Wood ❑ 04
Comal 0 08 Hamilton 0 07 Live Oak 0 11 Runnels 0 02 -Y-
Comanche 0 02 Hansford 0 01 Llano 0 07 Rusk 0 04 Yoakum 0 01
Concho 0 09 Hardeman 0 02 Loving 0 09 -S- Young 0 02
Cooke 0 03 Hardin 0 05 Lubbock 0 01 Sabine 0 05 -Z-
Coryell 0 07 Harris 0 06 Lynn 0 01 San 0 05 Zapata 0 11
Augustine
Cottle ❑ 02 Harrison 0 04 -M- San Jacinto 0 05 Zavala 0 08
Crane 0 09 Hartley 0 01 Madison 0 07 San Patricio 0 11
Crockett 0 09 Haskell 0 02 Marion 0 04 San Saba 0 07
Page 41 PHC RFP#537-16-142081
FORM B: PROPOSAL TABLE OF CONTENTS AND CHECKLIST
Legal Business Name of
Respondent:
This form is provided as your Table of Contents and to ensure the proposal is complete, proper signatures are included, and the required
assurances,certifications, and attachments have been submitted. Be sure to indicate page number.
FORM DESCRIPTION Included Page# Not
Applicable
A Face Page -completed,and proper signatures and date included ❑
A-1 Texas Counties and Regions List-completed and included ❑
B Proposal Table of Contents and Checklist -completed and included ❑
C Contact Person Information -completed and included ❑
D Administrative Information - completed and included (with supplemental documentation ❑
attached if required)
D-1 Governmental Entity-completed and included is respondent is a governmental agency ❑ ❑
D 2 Non-Profit and For-Profit Entity - completed and included if respondent is a non-profit or ❑ ❑
for-profit agency
E Exceptions Form -completed and included (with supplemental documentation attached if ❑
required)
F Respondent Background -completed and included ❑
G Assessment Narrative—completed and included ❑
H Performance Measures-completed and included ❑
H-1 Performance Measure Request for Exception-completed and included ❑ ❑
I Work Plan—completed and included ❑
Child Support Form [required—applies to for-profit entities only]- completed, signed ❑ ❑
and included
K Financial Management and Administration Questionnaire ❑ ❑
L Clinic Site Forms ❑
L-1 Clinic Site Readiness Forms ❑
Budget Summary Form and Detail Pages-download from HHSC Business Opportunities
APPENDIX
Awebsite completed and included (with most recently approved indirect cost agreement ❑
and letters of good standing if applicable.)
APPENDIX DSHS Assurances and Certifications ❑
APPENDIX HUB Subcontracting Plan ❑ ❑
Do not return the DSHS Assurances and Certifications.
Page 42 PHC RFP#537-16-142081
FORM C: PHC CONTACT PERSON INFORMATION
Legal Business
Name of
Respondent:
This form provides information about the appropriate contacts in the respondent's organization in addition to those on FORM A: FACE
PAGE. Complete all information for all contacts within your agency. Mark N/A if a contact does not apply to your agency. *All
phone numbers should be a direct line to the designated individual.* If any of the following information changes during the term of
the contract,please send written notification to the Contract Manager in the Contract Management Unit.
*Please ensure that all information is complete and accurate.*
Contact: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Contact: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Contact: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Contact: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Contact: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Page 43 PHC RFP#537-16-142081
FORM D: ADMINISTRATIVE INFORMATION
This form provides information regarding identification and contract history of the respondent, executive management, project
management, governing board members, and/or principal officers. Respond to each request for information or provide the required
supplemental document behind this form. If responses require multiple pages, identify the supporting pages/documentation with the
applicable request.
NOTE:Administrative Information may be used in screening and/or evaluating proposals.
Legal Business
Name of
Respondent:
Identifying Information
1. The respondent must attach the following information:
If a Governmental Entity complete Form D-1.
• Names (last, first, middle) and addresses for the officials who are authorized to enter
into a contract on behalf of the respondent.
If a Nonprofit or For Profit Entity complete Form D-2.
• Full names (last, first, middle), addresses, telephone numbers, titles and occupation of
members of the Board of Directors or any other principal officers. Indicate the office
held by each member (e.g. chairperson, president, vice-president, treasurer, etc.).
• Full names (last, first, middle), and addresses for each partner, officer, and director as
well as the full names and addresses for each person who owns five percent (5%) or
more of the stock if respondent is a for-profit entity.
2. Is respondent a nonprofit organization?
❑ YES ❑ NO
If YES, respondent must include evidence of its nonprofit status with the proposal. Any
one of the following is acceptable evidence. Check the appropriate box for the attached
evidence.
❑ (a)A copy of a currently valid IRS exemption certificate.
❑ (b)A statement from a State taxing body, State Attorney General, or other
appropriate State official certifying that the respondent organization has a
nonprofit status and that none of the net earnings accrue to any private
shareholders or individuals.
❑ (c)A copy of the organization's certificate of formation or similar document if it
clearly establishes the nonprofit status of the organization.
❑ (d)Any of the above proof for a State or national parent organization, and a
statement signed by the parent organization that the respondent organization
is a local nonprofit affiliate.
Page 44 PHC RFP#537-16-142081
FORM D: ADMINISTRATIVE INFORMATION continued
Conflict of Interest and Contract History
The respondent must disclose any existing or potential conflict of interest relative to the
performance of the requirements of this RFP. Examples of potential conflicts include an
existing or potential business or personal relationship between the respondent, its principal, or
any affiliate or subcontractor, with DSHS, the Health and Human Services Commission, or any
other entity or person involved in any way in any project that is the subject of this RFP.
Similarly, any existing or potential personal or business relationship between the respondent,
the principals, or any affiliate or subcontractor, with any employee of DSHS, or the Health and
Human Services Commission must be disclosed. Any such relationship that might be
perceived, or represented as a conflict, must be disclosed. Failure to disclose any such
relationship may be cause for contract termination or disqualification of the proposal. If,
following a review of this information, it is determined by DSHS that a conflict of interest exists,
the respondent may be disqualified from further consideration for the award of a contract.
Pursuant to Texas Government Code Section 2155.004, a respondent is ineligible to receive
an award under this RFP if the bid includes financial participation with the respondent by a
person who received compensation from DSHS to participate in preparing the specifications or
the RFP on which the bid is based.
3. Does anyone in the respondent organization have an existing or potential conflict
of interest relative to the performance of the requirements of this RFP?
❑ YES ❑ NO
If YES, detail any such relationship(s) that might be perceived or represented as a conflict.
(Attach no more than one additional page.)
4. Will any person who received compensation from DSHS or Health and Human
Services Commission (HHSC) for participating in the preparation of the
specifications or documentation for this RFP participate financially with respondent
as a result of an award under this RFP?
❑ YES ❑ NO
If YES, indicate his/her name,job title, agency employed by, separation date, and reason
for separation.
5. Will any provision of services or other performance under any contract that may
result from this RFP constitute an actual or potential conflict of interest or create
the appearance of impropriety?
❑ YES ❑ NO
If YES, detail any such actual or potential conflict of interest that might be perceived or
represented as a conflict. (Attach no more than one additional page.)
Page 45 PHC RFP#537-16-142081
6. Are any current or former employees of the respondent current or former
employees of DSHS or HHSC (within the last 24 months)?
n YES ❑ NO
If YES, indicate his/her name, job title, agency employed by, separation date, and reason
for separation.
7. Are any proposed personnel related to any current or former employees of DSHS or
HHSC?
❑ YES NO
If YES, indicate his/her name, job title, agency employed by, separation date, and reason
for separation.
8. Has any member of respondent's executive management, project management,
governing board or principal officers been employed by DSHS or HHSC 24 months
prior to the proposal due date?
❑ YES ❑ NO
If YES, indicate his/her name,job title, agency employed by, separation date, and reason
for separation.
9. If the respondent is a private nonprofit organization, does the executive director or
other staff serve as voting members on the organizations governing board?
❑ YES ❑ NO
10. Is respondent or any member of respondent's executive management, project
management, board members or principal officers:
• Delinquent on any state, federal or other debt;
• Affiliated with an organization which is delinquent on any state, federal or other debt;
or
• In default on an agreed repayment schedule with any funding organization?
❑ YES ❑ NO
If YES, please explain. (Attach no more than one additional page.)
11. Has the respondent had a contract suspended or terminated prior to expiration of
contract or not been renewed under an optional renewal by any local, state, or
federal department or agency or non-profit entity?
❑ YES ❑ NO
If YES, indicate the reason for such action that includes the name and contact
information of the local, state, or federal department or agency, the date of the contract
and a contract reference number, and provide copies of any and all decisions or orders
related to the suspension, termination, or non-renewal by the contracting entity.
Page 46 PHC RFP#537-16-142081
12. Does this proposal include financial participation by a person or entity that has
been convicted of violating federal law, or been assessed a penalty in a federal
civil administrative enforcement action, in connection with a contract awarded by
the federal government for relief, recovery or reconstruction efforts as a result of
Hurricanes Rita or Katrina or any other disaster occurring after September 24,
2005, under Government Code 2261.053?
❑ YES ❑ NO
If YES, please explain. (Attach no more than one additional page.)
13. Has respondent had a contract with DSHS within the past 24 months?
❑ YES ❑ NO
If YES, list the DSHS contract and attachment number(s):
DSHS Contract Number(s)
If NO, respondent must be able to demonstrate fiscal solvency. Submit a copy of the
organization's most recently audited balance sheet, statement of income and expenses and
accompanying financial footnotes. If an organization does not have audited financial
statements, submit a copy of the organization's most recent IRS Form 990 and an
explanation why an audited financial statement is not available. DSHS will review the
documents that are submitted and may, at its sole discretion, refect the proposal on the
grounds of the respondent's financial capability.
ALL ADDITIONAL PAGES REQUIRED BY RESPONSES TO FORM D, SHOULD BE
INSERTED HERE.
Page 47 PHC RFP#537-16-142081
FORM D-1: GOVERNMENTAL ENTITY
Authorized Officials
Legal Business
Name of
Respondent:
Include the full names (last, first, middle) and addresses for the officials who are authorized to
enter into a contract on behalf of the respondent.
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Page 48 PHC RFP#537-16-142081
FORM D-2: NONPROFIT OR FOR-PROFIT ENTITY
Board of Directors and Principal Officers
Legal Business
Name of
Respondent:
Include the full names (last, first, middle), addresses, telephone numbers, and titles of
members of the Board of Directors or any other principal officers. Indicate the office/title held
by each member (e.g. chairperson, president, vice-president, treasurer, etc.),In addition, if
entity is a for-profit, include the full names and addresses for each person who owns five
percent (5%) or more of the stock.
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Name: Mailing Address(incl.street,city,county,state,&zip):
Title:
Phone: Ext.
Fax:
Email:
Page 49 PHC RFP#537-16-142081
FORM E: EXCEPTIONS FORM
FORM E: EXCEPTIONS FORM
RFP # 537-16-142081
Legal Business Name
of Respondent:
This is the approved format for the respondent to: (1) state that no exceptions are
being made to the requirements, terms, conditions, or certifications in the RFP or
attachments, addendums, or revisions to the RFP or General Provisions, or (2) list all
exceptions to any requirements, terms conditions, certifications or deliverables in the
RFP or General Provisions.
Respondent must submit this form with their response.
Instructions:
• If no exceptions are being requested to any issue of the RFP, respondent must check
the `no exception' box below and leave the table blank.
• If exceptions are being requested, use the table below and fill in all columns for each
exception.
• Ensure the RFP section number and page number or the number of the term or
condition of the issue is stated.
• Ensure each exception is described fully or by reference to the exact location within the
proposal and/or general provisions.
• Ensure it is stated whether the exception is part of a proposal deliverable with a clear
citation to the deliverable.
• Provide an explanation of why the exception is being proposed, and any alternatives
being proposed to the issue in the RFP.
• Add more table lines as necessary.
• If more space for explanations or alternatives is reasonably needed, list the exception
on this form and reference the attached page(s) — Ensure each attached page clearly
identifies the line item it refers to.
• Any alternatives may also be embedded in the proposal narrative as appropriate to
make the narrative clear, but in the proposal narrative the exception must be noted with
the line item number on this form.
❑ If no exceptions are being
requested, check this box and
leave the table below blank
Page 50 PHC RFP#537-16-142081
FORM E: EXCEPTIONS FORM
RFP # 537-16-142081
Legal Business Name
of Respondent:
TABLE OF EXCEPTIONS
Exception RFP Section Full description State if the Explanation of
No. No. and Page of exception exception is why the
No. or no. of requested or part of a exception is
term or reference to proposal being proposed
condition in the exact location of deliverable with and any
general full description if a clear citation proposed
provisions to found ; to the alternatives to
which exception elsewhere in deliverable the issue
is requested proposal and/or
general
provisions.
1.
12 I-
3.
I4.
1 5.
6.
17.
8.
19.
110.
11.
[ 12.
[13.
14.
15.
16.
17.
18.
( 19.
20. I
Page 51 PHC RFP#537-16-142081
FORM F: RESPONDENT BACKGROUND
Legal Business Name
of Respondent:
Respondent must provide a narrative description of the organization, staff, systems, and oversight
structure. In respondent proposal, label as "Form F: (Name of Respondent) Respondent
Background"and specifically address each of the elements listed below, as related to the
services proposed in this RFP response, numbering them as indicated. (Maximum of five (5)
pages, as indicated in sections below.) Note: #4 below, respondent's Organization Chart and
the Table of Contents from the organization's operating policies and procedures are not
included in the page limit. These two documents should be labeled with the respondent's name and
attached after Form F: Respondent Background.
1. Attach a one-page executive summary describing the organization's purpose, vision,
mission, and values statements, along with a description of how the governing board is involved
in the operations of the organization. (1 page max)
2. Provide a detailed description of the organization's structure, management systems and
lines of authority that are appropriate and adequate for the size and scope of the organization.
(1 page max)
3. Describe respondent's experience, knowledge and expertise with subcontracting.
Specifically address each element listed below: (3 pages max)
A. History with subcontracting with other agencies/providers;
B. Experience in developing Letters of Agreement and negotiating with subcontractors;
C. Experience in providing technical assistance to subcontractors, including budget
development and management;
D. Experience in performing program monitoring of subcontractors, including monitoring of
professional and clinical services;
E. Staff position(s) that will be responsible for monitoring subcontractors and what
qualifications will be required;
F. Policies and procedures for monitoring subcontractors that provide direct client services;
and
G. Staff position(s) that are anticipated for providing training and technical assistance to
subcontractors on data collection, data submission, and data quality improvement.
4. Attach a current organization chart and a Table of Contents from organization's
operating policies and procedures: The organization chart must include the appropriate
oversight structure (e.g., Board, City Council, County Commissioners, etc.), CEO, CFO,
Medical Director*, and a staffing structure that will support service provision. On the chart,
identify the staff who manages clinic operations. *Note: The Medical Director and other
clinicians must be licensed to practice medicine in Texas and to provide primary health
care services. The State of Texas Medical License number for the Medical Director
should also be provided. (These attachments are not included in page limit.)
Page 52 PHC RFP#537-16-142081
FORM G: ASSESSMENT NARRATIVE
Legal Business Name
of Respondent:
Multiple data sources and assessments exist and the respondent is encouraged to use those
resources when completing this form. In respondent proposal, label as "Form G: (Name of
Respondent) Assessment Narrative"and specifically address each of the elements listed below, as
related to the services proposed in this RFP response, numbering them as indicated (Maximum of 6
pages, as indicated in sections below.)
1. Provide a brief synopsis of the respondent's current service area as a whole, describing: (2 page
max)
A. Geographic boundaries (urban or rural, physical environment, etc.);
B. Demographic data (age, gender, ethnicity, race, etc.);
C. Socioeconomic data (per capita income, poverty levels, uninsured/underinsured,
unemployment, occupational data, etc.); and
D. Health status (e.g., key morbidity/mortality statistics, chronic disease burden, insurance
coverage status, healthcare infrastructure, rate of potentially preventable hospitalizations, etc.);
2. Describe respondent's organization, including: (1 page max)
A. Health services that respondent currently provides to the low-income and uninsured population;
B. Respondent's total budget, including funding sources and amounts (federal, state, local, and
other); and
C. Number of clients currently receiving primary health care services;
3. Describe the proposed DSHS primary health care project and how it differs from respondent's
current population and service base, including: (2 page max)
A. Proposed service area (healthcare infrastructure, access to care, Health Profession Shortage
Area (HPSA) designation, etc.);
B. Target project population and how it differs from respondent's organization's current population
base (Include race/ethnic, socioeconomic status information, and health risk indicators);
C. Explain the proposed services to be provided and how they differ from the current services
provided by respondent organization;
D. Percentage of DSHS PHC funds requested for proposed project compared to respondent
organization's total budget;
E. Explain why the organization believes that it has the capacity to achieve the service levels
indicated in the proposal.
4. Describe gaps in resources that exist in the proposed service area (e.g., transportation, childcare,
language, disability, etc.) and potential barriers to delivering DSHS PHC services to the target
population. (1 page max)
Page 53 PHC RFP#537-16-142081
FORM H: PERFORMANCE MEASURES
Legal Business Name of
Respondent:
Respondent must include the performance measure in the proposal. The proposed target levels of
performance may be negotiated and agreed upon by respondent and DSHS if respondent is selected
to negotiate a contract. In the event a contract is awarded, respondent agrees that this performance
measure will be used to assess, in part, the respondent's effectiveness in providing the primary health
care services described. The performance measure is included in the contractor's statement(s) of
work, and DSHS expects that by the end of the contract period the contractor will have met it.
Reimbursement for PHC Services
Initially, the PHC Program will use a categorical cost reimbursement method. This is a payment mechanism by which
contractors are reimbursed for allowable costs incurred up to the total award amount specified in the cost reimbursement
contract. Incurred costs must be related to program activities and based on an approved eight-category line-item categorical
budget. Later during the project period for this procurement a claim-based, automated system for submission and
reimbursement of PHC clinical services may be used. At that time, reimbursement for services procured by this RFP will be
available by two methods: fee-for-service and cost reimbursement;contractors will be required to use the automated system
as the fee for service billing system and the client services voucher and reporting system (see Part 1, I Introduction and
Definitions, C, Use of Funds).
Instructions: Complete Tables #1 and #2 below. The statewide average PHC cost per client for
clinical services is estimated to be $180. The projected total number of unduplicated PHC clients to
whom the agency will provide services should be based on the total funding amount requested (must
be the same amount as on the Face Page: Form A, line #10) and the average cost per client.
*If contractor's average cost per client exceeds the statewide average PHC cost per client of
$180, contractor must provide an explanation/justification below.
Note: The total amount of PHC funding requested (Table 2) must be the same dollar amount as
the total amount of PHC funding requested on Form A: Face Page, line #10.
The performance measure for PHC is:
Total number of The estimated total number of unduplicated DSHS PHC clients to
unduplicated clients whom the agency will provide primary health care services.
Table 1: PHC Clients
1 TOTAL number of Unduplicated DSHS PHC Clients to be provided
services with DSHS PHC funds
Table 2: PHC Funds
1 TOTAL PHC Funding Amount Requested - (This amount includes ALL $
unduplicated PHC clients to be served in Table 1)
Page 54 PHC RFP#537-16-142081
FORM H-1: REQUEST FOR EXCEPTION TO STATEWIDE AVERAGE COST PER
CLIENT
*Explanation/justification of average cost per client if contractor's average cost per
client exceeds statewide average of$180: (maximum of 1 additional page)
Page 55 PHC RFP#537-16-142081
FORM I: WORK PLAN
Legal Business Name of
Respondent:
In respondent proposal, label as "Form I: (Name of Respondent) Work Plan" and specifically
address each of the elements listed below, numbering them as indicated. The plan, as related to the
services proposed in this RFP response, must be comprehensive and include timelines for
implementation. (Maximum of six (6) pages, as indicated in sections below. Required
attachments are not included in page number limit.)
Proposed#of clients to be served:
1. Summarize the number of proposed clients to be served and the expected utilization rates of the proposed services
covered by this project. (1 page max)
2. Describe delivery systems,workforce, policies, support systems(i.e.,training, research,technical assistance, and
information,financial and administrative systems)and other infrastructure available to achieve service delivery of
the required services. Specifically,address how priority services listed below will be delivered: (1 page max)
A. Diagnosis and treatment;
B. Preventative health services;
C. Family Planning services;
D. Emergency medical services
E. Health education;
F. Laboratory, x-ray, nuclear medicine,or other appropriate diagnostic services.
3. Describe coordination with other health care providers or human services entities in the service area. Delineate
how duplication of services will be avoided. If respondent receives other federal, state, or local funds dedicated to
providing preventive and primary health care services, explain how additional state funds would improve existing
services. (1 page max)
4. Incorporating the barriers identified in the Assessment Narrative(Form G), describe how the respondent proposes
to ensure access to services given these barriers(e.g., language,transportation, appointment and waiting times,
childcare, disability, location, hours of service delivery,etc.). (1 page max)
5. Describe data collection,tracking,follow up, and financial management systems, including: (1 page max)
A. How medical data is collected and tabulated,who will be responsible for data collection and reporting required
elements to DSHS, include an example of how data are used for program evaluation within the agency;
B. How the respondent will ensure accuracy and timeliness in submitting required elements;
C. How data will be stored to protect confidential client information; and
D. Describe billing systems.
6. Describe internal Quality Management(QM)processes utilized to monitor services, identify staff responsible for
ensuring that the identified processes are implemented and documented. The description must include the
following: (1 page max)
A. Role of the QM Committee;
B. Medical Director's involvement in the QM activities;
C. Activities utilized to identify areas needing improvement and the frequency of those activities;
D. Activities to ensure correction and follow-up to findings identified;
E. Utilization and frequency of client satisfaction surveys;
F. System utilized to identify and monitor adverse outcomes;
G. Process for identifying performance and outcome measures; and
H. Process utilized to develop protocols and Standing Delegation Orders.
7. Attach a letter of agreement from each subcontractor and indicate what service(s)will be provided. (Not included
in page count)
8. Attach a minimum of three(3)letters of support from government officials and/or community partners. (Not
included in page count)
Page 56 PHC RFP#537-16-142081
FORM I: WORK PLAN GUIDELINES
The following provides guidance for the scope of work covered by the core services covered under this program. This
scope is meant as a guide,for a more detailed and comprehensive list, see the PHC Policy Manual.Within the work
plan, prenatal and dental services should be specifically addressed, not just within the scope of preventative health
services.
PRIMARY& PREVENTIVE SCOPE OF SERVICES
CARE SERVICES
Diagnosis and treatment of common acute and chronic disease that affect the
general health of the client. Services include first contact with a client for an
undiagnosed health concern as well as continuing care of varied medical
conditions not limited by cause or organ system. Services must not be limited to
specialized care such as family planning. Physician services. Services must be
medically necessary and provided by a physician in the doctor's office, clinic, or
facility other than a hospital setting.
Physician assistant(PA)services. These services must be medically necessary
Diagnosis&Treatment and provided by a PA under the direction of a physician and may be billed by
and paid to the supervising physician.
Advanced practice nurse (APN) services. An APN must be licensed as a
registered nurse (RN) within the categories of practice, specifically, a nurse
practitioner, a clinical nurse specialist, a certified nurse midwife (CNM), and a
certified registered nurse anesthetist (CRNA), as determined by the Board of
Nurse Examiners. APN services must be provided within the scope of practice
of an APN, and covered in the Texas Medicaid Program, and under the direction
of a physician.
Services must include, but are not limited to:
(a) Immunizations. These services are provided in an appropriate setting for
diseases that are preventable by vaccines.
(b) Cancer screening services. Services must be medically necessary and by
clinical recommendation. Services include: clinical breast examinations,
mammograms, pelvic examinations, and cancer screening. Specialty care
Preventive Health Services services such as mammograms may be provided by a sub-contractor.
(c) Screenings for Chronic Conditions. These services may include screenings
for hypertension, diabetes and other chronic conditions as indicated.
(d) Health screening. Screening to determine the need for intervention and
possibly a more comprehensive evaluation. Health screening may include
taking a personal and family health history and performing a physical
examination, laboratory tests or radiologic examination, and may be
followed by counseling, education, referral,or further testing.
These are preventive health and medical services that assist an individual in
controlling fertility and achieving optimal reproductive and general health.
Services include: health check-up & physical exam; birth control methods (pills,
Family Planning Services IUC, condoms, shot, ring, etc.); natural family planning; lab tests for sexually
transmitted infections (STI), pregnancy testing; counseling regarding
abstinence; pre-conception (planning for a healthy pregnancy); nutrition; and
infertility.
Planned learning experiences based on sound theories that provide individuals,
Health Education groups, and communities the opportunity to increase knowledge and skills
needed to make quality health decisions.
Services must be for urgent care for an unexpected health condition requiring
Emergency Medical Services immediate attention as determined by the appropriate medical staff, and must
be services that can be treated in a primary care clinic or setting.
Diagnostic, Laboratory, and Services must be medically necessary. These are technical laboratory tests and
Radiological Services radiological services ordered and provided by, or under the direction of, a
physician, in an office or a facility other than a hospital inpatient setting.
Page 57 PHC RFP#537-16-142081
FORM J: CHILD SUPPORT CERTIFICATION
I TEXAS (REQUIRED - Applies to For-Profit Entities Only)
DepSate,ti ,It S
Stale Health Services
Department of State Health Services
Child Support Certification
The Texas Family Code, §231.006, places certain restrictions on child support obligors. Contracts with
governmental entities or nonprofit corporations are not subject to §231.006.
The contractor identified below is not a governmental entity or a nonprofit corporation and certifies to
the following:
1. The contractor is: (check one)
❑ An individual or sole proprietor, or
EJ A business entity (corporation, partnership, joint venture, limited liability company,
association, etc.)
2. The contractor certifies the following is a complete list of the names and social security numbers of
either (A) the individual or sole proprietor who is the contractor or (B) each partner, shareholder, or
owner with an ownership interest of at least 25% of the contractor/business entity: (attach additional
sheet if necessary).
(A) Printed Name:
Social Security Number:
(B) Printed Name:
Social Security Number:
3. Under the Texas Family Code, §231.006, the contractor certifies that the individual or business
entity named in this contract, bid, or application is not ineligible to receive the specified grant, loan,
or payment and acknowledges that this contract may be terminated and payment withheld if this
certification is inaccurate. A child support obligor who is more than 30 days delinquent in paying
child support or a business entity in which the obligor (who is more than 30 days delinquent) is the
sole proprietor, partner, shareholder, or owner with an ownership interest of at least 25% is not
eligible to receive the specified grant, loan or payment. The contractor understands that it is the
contractor's responsibility to verify whether a child support obligor who is more than 30 days
delinquent is the sole proprietor, partner, shareholder or owner with an ownership interest of at least
25%.
4. Printed Name of Contractor:
Printed Name of Authorized Representative:
Signing this Certification:
Signature of Authorized Representative:
Date:
Page 58 PHC RFP#537-16-142081
FORM K: FINANCIAL MANAGEMENT AND ADMINISTRATION
QUESTIONNAIRE
Name of Organization:
ACCOUNTING SYSTEM
The type of accounting system often depends on the size of the organization. Briefly describe your
organization's accounting system including:
a) Is the accounting system computerized, manual or a combination of both;
b) How are different types of transactions (e.g., cash disbursements, cash receipts, revenues, journal entries)
recorded and posted to the general ledger;
c)When do you close your general ledger(e.g., monthly by the 10th of the following month);
d) How are transactions organized, maintained, and summarized in financial reports. If your accounting system
is computerized, indicate the name/type.
Answer each of the following questions with either a "yes" or "no" answer by checking the respective box.
1. Is your accounting system organized to allow an auditor to trace financial
report balances through the general ledger and other summary
ledgers/journals to each detail accounting transaction and supporting source
documentation?
❑ YES ❑ NO
2. Does your accounting system have the capability of identifying the receipt and
expenditures of program funds and program income separately for each DSHS
contract/program attachment?
❑ YES ❑ NO
Page 59 PHC RFP#537-16-142081
3. Does your accounting system provide for the recording of expenditures for
each program attachment by the budget cost categories shown in the
proposed budget?
❑ YES ❑ NO
4. Does your accounting system provide for the segregation of direct and
indirect expenses and the allocation of indirect costs?
❑ YES ❑ NO
5. Are time records (e.g., time sheets) maintained for all employees where their
actual time/effort is recorded and specifically identified to a particular cost
objective?
❑ YES ❑ NO
6. Is the employees' time/effort that is recorded on the time record the
source/basis of the calculation of salary/wage costs recorded in the general
ledger for each cost objective?
❑ YES ❑ NO
GENERAL ADMINISTRATION & INTERNAL CONTROLS
1. Is the staff who will be responsible for the financial management of the award
generally familiar with the existing regulations and guidelines containing the
cost principles and financial administrative requirements applicable to state
and federal contracts/grants?
❑ YES ❑ NO
2. Does your organization have written accounting policies and procedures?
❑ YES ❑ NO
3. Are generally accepted accounting principles followed for separation of duties
regarding receipts and deposit of funds and payment of goods and services?
❑ YES ( I NO
Are procedures in place with adequate controls to ensure that receipts and
4. disbursements are authorized and appropriately documented?
Page 60 PHC RFP#537-16-142081
❑ YES ❑ NO
5. Are all disbursements approved prior to payment?
❑ YES ❑ NO
6. Is there any additional review or special approval required for checks
exceeding a specific dollar amount?
❑ YES ❑ NO
7 Are there written procedures and internal controls established for the
procurement of goods and services?
❑ YES ❑ NO
8. Do purchase orders/requisitions require specific approvals from authorized
individuals in the requesting department?
❑ YES ❑ NO
9. Are supporting documents (invoices, receipts, approvals, receiving reports,
canceled checks, etc.) maintained for each disbursement and on file for easy
location and retrieval?
❑ YES ❑ NO
10. Do supporting documents accompany checks for the check signer's
signature?
❑ YES ❑ NO
11. Are supporting documents marked when paid to prevent reuse or duplication
of payment?
❑ YES ❑ NO
12. Are invoices coded to identify allocation of payment by cost objective and
sub-account?
❑ YES ❑ NO
Page 61 PHC RFP#537-16-142081
13. Does your organization stay current with payments of its accounts payable,
payroll taxes and other liabilities, loans, taxes, etc.?
❑ YES ❑ NO
14. As program income is to be used for program purposes, are there
procedures and controls to ensure proper use, accountability, and
allocation?
❑ YES ❑ NO
15. Do you have written personnel policies?
❑ YES ❑ NO
16. Does your policy require individual daily time and attendance records for
personnel (part-time, full-time, and/or in-kind volunteers)?
❑ YES ❑ NO
17. Do procedures ensure that time and attendance reports can be specifically
traced to costs recorded in the general ledger for each payroll period for each
cost objective?
❑ YES ❑ NO
18. Do you have written job descriptions with set salary levels for each
employee?
❑ YES n NO
19. Do you have on file authorizations covering rates of pay, withholding and
deductions for each employee?
❑ YES ❑ NO
The Financial Management and Administration Questionnaire must be signed by an authorized person
who has either completed or reviewed the form and can attest to the accuracy of the information
provided.
Approved by:
Print Name:
Signature:
Title:
Page 62 PHC RFP#537-16-142081
FORM L: PHC CLINIC SITES Instructions
Instructions: Complete a separate clinic site form for each existing or proposed clinic site for which FY2016
DSHS PHC funds are requested and number sites consecutively. Indicate source of funding for each clinic on
form. Information provided on clinic site forms is used to update DSHS websites and public databases;
therefore, each clinic form must contain current and accurate information.
Legal Name of Respondent Respondent's legal name.
Clinic Site# of Example: Clinic Site#1 of 5 for the first clinic site out of five clinic sites, Clinic
Site#2 of 5 for the second clinic site of five,etc.
CLINIC SITE INFORMATION:
Clinic Name to Appear on Website Name of the clinic as it will appear on the DSHS website locator. (The name
Locator should be recognizable to clients.)
Service Area List counties served by that specific clinic site, NOT all counties served by
the entire project. Note:Counties served by all clinics must match
counties listed on Form A: Texas Counties and Regions List.
Clinic Contact Person Name of contact person for that clinic site.
Phone Phone number for the clinic.
Location of Site Clinic location(e.g., Texas Medical Center/Smith Tower)
Fax Fax number for the clinic.
Street Address Physical address of clinic. (Do Not enter a P.O. Box.)
City/County/Zip Code City,county and zip code of clinic.
HSR Health Service Region where clinic is located.
Pharmacy License# Current pharmacy license number for the clinic(if applicable); or N/A for Not
Applicable.
TPI# Texas Provider Identifier#for the clinic,or date application submitted. Enter
the TPI#that the clinic will use to bill TMHP for DSHS PHC services.
The TPI#for each clinic site should be unique.
NPI# National Provider Identifier#for the clinic,or date application submitted.
Subcontractor Site For each clinic site, indicate whether that particular site is subcontracted by
the respondent to another entity for the provision of services.
CLINIC HOURS AND SERVICES:
Hours of Operation List the operating hours of each clinic site for each day of the week broken
into morning (e.g., 8:00 a.m.—Noon), afternoon (e.g. 12:01 p.m.—5:00
p.m.), and evening hours(e.g., 5:01 p.m.—8:00 p.m.). Indicate days of the
week when the clinic is closed(e.g.Tuesday—closed).
Services Provided/Clinic Type List the type of services provided or type of clinic for each day of the week.
For example, Monday=child health clinic, Wednesday=dental clinic,etc.
#Monthly Clinics List the total number of clinics each month by the day of the week,e.g.,
Monday=4 clinics per month;Tuesday=0 clinics per month,etc.
Total Hours/Month List the total number of hours of operation per month for each clinic site(e.g.,
Clinic Site 1 = 128 hours per month; Clinic Site 2= 160 hours per month,
etc.)
Total#Clinics Per Month List the total number of clinics held per month per clinic site(e.g., Clinic Site
1 = 16, Clinic Site 2=20,etc.)
Important: Any changes in clinic information must be reported in writing to the appropriate DSHS Contract Manager in a
timely manner. Programmatic or operational changes must be made in accordance with requirements outlined in the DSHS
General Provisions.
Page 63 PHC RFP#537-16-142081
FORM L: PHC CLINIC SITES
Legal Business Name of Contractor: Clinic Site #
of
Instructions: CLINIC SITE INFORMATION: Complete this form for EACH clinic site that will provide PHC
beginning September 1, 2015. Information provided in the below table will be displayed on the FCHS Clinic
Locator: www.txclinics.com.
*Please ensure that all information is accurate.*
Clinic Name:
Street Address: Suite:
City: County: Zip Code: HSR:
Clinic APPOINTMENT Phone#:
Clinic PRIMARY Phone#: Fax:
Service Area
(counties to be served
by this clinic site):
Contact Person:
Pharmacy License#: Class: TPI#: NPI#:
Subcontractor Site: ❑ Yes ❑ No
Mobile Site: ❑ Yes ❑ No
CLINIC HOURS
DAY HOURS OF OPERATION #MONTHLY CLINICS
Morning Afternoon Evening(after 5pm)
From To From To From To
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
TOTAL HRS/MONTH
TOTAL CLINICS/MONTH
Page 64 PHC RFP#537-16-142081
FORM L-1: PHC CLINIC SITE READINESS
Legal Business Name of Respondent: Clinic Site#
of
Clinic Name to Appear on Website
Locator:
Instructions for Clinic Site Readiness Table: MUST COMPLETE A SEPARATE FORM L-1 FOR EACH
CLINIC SITE INCLUDED IN PROPOSAL AND NUMBER FORMS L-1 TO MATCH CORRESPONDING
CLINIC NUMBER IN FORM L.
Appropriate signage to identify Check that clinic sites have signage that identifies services provided at each
funded entity. site(Yes/No).
Space for clinical and administrative Check that clinic sites have adequate space to house clinical and
staff. administrative staff needed to run the clinics(Yes/No).
Computer systems with following This question determines whether responder has adequate computer
minimum functionality: functionality for clinic sites.
Internet Check if clinic computers have internet access(Yes/No).
Email Check if clinic computers have email access(Yes/No).
Class D pharmacy Check if clinic has at least a Class D pharmacy(Yes/No).
Locked storage for charts, records, Check if there is locked storage at the clinic sites(Yes/No).
medications and medical supplies
Proper Disposal for Medical Waste Check if clinics have proper disposal for medical waste(Yes/No).
CLIA certification for level of tests Check if clinics have CLIA certification for the level of tests performed
performed. (Yes/No).
Handicap accessible clinic sites that Check if clinic sites are accessible for persons with disabilities, and are
are geographically close to target located close to target population(Yes/No).
population.
Appropriate facility(ies)where
services can be delivered with clean Check if respondent operates facilities with clean exam rooms, space for
exam rooms, space for client intake, client intake and client waiting area(Yes/No).
and a place for clients to wait.
Appropriate use of interpreter and Check if there are resources for interpreter and language translation
language translation services services,and if services are used appropriately(Yes/No).
(including resources for both).
Compliance with ADA requirements Check if clinic sites are ADA compliant(Yes/No).
CLINIC READINESS
Appropriate signage to identify funded entity. ❑ Yes ❑ No
Space for clinical and administrative staff? ❑Yes ❑ No
Computer systems with the following minimum functionality:
• Internet ❑Yes ❑ No
• Email 0 Yes ❑ No
Locked storage for charts, records, medications and medical supplies ❑ Yes ❑ No
Proper Disposal for Medical Waste 0 Yes ❑ No
CLIA certification for level of tests performed 0 Yes ❑ No
Class D Pharmacy(or have applied for a Class D Pharmacy License) 0 Yes ❑ No
Handicap-accessible clinic sites that are geographically close to target
0 Yes ❑ No
population
Appropriate facility(ies)where services can be delivered with clean exam
0 Yes ❑ No
rooms, space for client intake, and a place for clients to wait.
Appropriate use of interpreter services and language translation (including
0 Yes ❑ No
resources for both).
Compliance with ADA requirements 0 Yes 0 No
Page 65 PHC RFP#537-16-142081
APPENDICES
APPENDIX A: BUDGET SECTION
Detailed budget category forms, general information, and instructions are located on the HHSC
Business Opportunities website at: http://www.hhsc.state.tx.us/about hhsc/BusOpp/contract-
opportunities.asp.
Specific instructions for completing budget forms for this RFP
NOTE: In addition to the general information and instructions for the budget forms provided at the link
above, respondents must follow the specific instructions below for PHC budgets.
For DSHS PHC funds requested:
• On the Personnel Budget Category Detail Form - include only staff positions that will work directly
on the proposed PHC Project (e.g., a CEO, CFO, etc. should be budgeted in the Indirect Category, not
in the Personnel category).
• In the row for Fringe Benefits - the DSHS share will be a calculated amount not to exceed 30% of
the approved DSHS share of direct Personnel costs.
• On the Travel Budget Category Detail Form - respondents should enter proposed in-state travel
costs ONLY related to this State-funded DSHS PHC Program. Respondent must include funds for a
minimum of two (2) staff members to attend two (2) meetings in Austin —one meeting for two (2) days
and one meeting for three (3) days.
• DSHS must approve any staff workshops/conferences/training, etc. budgeted with PHC funds.
• On the Indirect Costs Form - the DSHS share will be a calculated amount not to exceed 15% of the
approved DSHS share of direct Personnel costs.
Respondent must insert budget section here.
Page 66 PHC RFP#537-16-142081
APPENDIX B: DSHS ASSURANCES AND CERTIFICATIONS
Note: It is not required that the respondent return the DSHS Assurances and
Certifications with the proposal. Some of these Assurances and Certifications may not be
applicable to your project. If you have questions, contact the contact person named in
this RFP. These assurances and certifications will remain in effect throughout the project
period of this solicitation and the term of any contract between respondent and DSHS.
As the duly authorized representative of the respondent, my signature on FORM A: FACE
PAGE certifies that the respondent:
1. Is a legal entity legally authorized and in good standing to do business with the State of Texas and has
the legal authority to apply for state/federal assistance, and has the institutional, managerial and financial
capability and systems (including funds sufficient to pay the non-state/federal share of project costs) to
ensure proper planning, management and completion of the project described in this proposal; possesses
legal authority to apply for funding; that a resolution, motion or similar action has been duly adopted or
passed as an official act of the respondent's governing body, authorizing the filing of the proposal
including all understandings and assurances contained therein, and directing and authorizing the person
identified as the authorized representative of the respondent to act in connection with the proposal and to
provide such additional information as may be required;
2. Under Government Code Section 2155.004, is not ineligible to receive the specified contract and
acknowledges that this contract may be terminated and payment withheld if this certification is incorrect.
NOTE: Under Government Code Section 2155.004, a respondent is ineligible to receive an award under
this RFP if the bid includes financial participation with the respondent by a person who received
compensation from DSHS to participate in preparing the specification of RFP on which the bid is based;
3. Has a financial system that identifies the source and application of DSHS funds and program income in a
unique set of general ledger account numbers, permits preparation of reports required by the contract,
permits the tracing of funds expended and program income, allows for the comparison of actual
expenditures to budgeted amounts, and maintains accounting records that are supported by verifiable
source documents;
4. Will give (and any parent, affiliate, or subsidiary organization, if such a relationship exists, will give)
DSHS, HHSC Office of Inspector General, the Texas State Auditor, the Comptroller General of the United
States, and if appropriate, the federal government, through any authorized representative, access to and
the right to examine all records, books, papers, or documents related to the award; and will establish a
proper accounting system in accordance with generally accepted accounting standards or agency
directives;
5. Will not supplant funds (i.e. use funds from a contract awarded as a result of this RFP to replace or
substitute existing funding from other sources that also supports the activities that are the subject of the
contract), but rather will use funds from the contract to supplement any existing funds currently available
for any such activities;
6. Will establish safeguards to prohibit employees from using their positions for a purpose that constitutes or
presents the appearance of personal or organizational conflict of interest, or personal gain;
7. Will ensure that no officer, employee, or member of the respondent's governing body or of the
respondent's contractor will vote or confirm the employment of any person related within the second
degree of affinity or the third degree of consanguinity (as defined in Texas Government Code Chapter
Page 67 PHC RFP#537-16-142081
573) to any member of the governing body or to any other officer or employee authorized to employ or
supervise such person. This prohibition does not prohibit the continued employment of a person who has
been continuously employed for a period of two years, or such other period stipulated by local law, prior to
the election or appointment of the officer, employee, or governing body member related to such person in
the prohibited degree;
8. Has not given, offered to give, nor intends to give, at any time hereafter any economic opportunity,
present or future employment, gift, loan, gratuity, special discount, trip, favor, or service to any employee
or official of DSHS or HHSC, in connection with this solicitation or procurement; does not have nor will it
knowingly acquire any interest that would conflict in any manner with the performance of its obligations
under any awarded contract that results from this RFP;
9. Will honor for 90 days after the proposal due date the technical and business terms contained in the
proposal;
10. Will initiate the work after receipt of a fully executed contract and will complete it within the contract
period;
11. Will not require a client with limited English proficiency to provide or pay for the services of a translator or
interpreter;
12. Will identify and document on client records the primary language/dialect of a client who has limited
English proficiency and the need for translation or interpretation services;
13. Will make every effort to avoid use of any persons under the age of 18 or any family member or friend of
a client as an interpreter for essential communications with clients who have limited English proficiency.
However, a family member or friend may be used as an interpreter if this is requested by the client and
the use of such a person would not compromise the effectiveness of services or violates the client's
confidentiality, and the client is advised that a free interpreter is available;
14. Will comply with the Uniform Grant Management Act (UGMA), Texas Government Code, Chapter 783, as
amended, and the current Uniform Grant Management Standards (UGMS), issued by the Governor's
Budget and Planning Office, applicable Office of Management and Budget Federal Circulars, and if
applicable the Federal awarding agency Common Rule and U.S. Department of Health and Human
Services Grants Policy Statements, which apply as terms and conditions of any resulting contract. A copy
of the UGMS manual and federal references are available upon request;
15. Will remain current in its payment of franchise tax or is exempt from payment of franchise taxes, if
applicable;
16. Will comply, if applicable, with Texas Family Code, § 231.006, regarding Child Support, and certifies that it
is not ineligible to receive payment if awarded a contract, and acknowledges that any resulting contract
may be terminated and payment may be withheld if this certification is inaccurate;
17. Will comply with the non-discriminatory requirements of Texas Labor Code, Chapter 21, which requires
that certain employers not discriminate on the basis of race, color, disability, religion, sex, national origin,
or age;
18. Will not charge a fee or profit. A profit and/or fee are considered to be an amount in excess of actual
allowable costs that are incurred in conducting an assistance program;
19. Will comply with all applicable requirements of all other state/federal laws, executive orders, regulations,
and policies governing this program;
Page 68 PHC RFP#537-16-142081
20. As the prospective participant, and any of the prospective participant's principals (collectively,
participants):
A. are not presently disqualified, debarred, suspended, proposed for debarment, declared ineligible,
or voluntarily excluded from covered transactions by any federal department or agency; in
accordance with 2CFR Parts 376 and 180 (parts A-I), and 45 CFR Part 76 (or comparable federal
regulation);
B. have not within a 3-year period preceding this proposal been convicted of or had a civil judgment
rendered against them for commission of fraud or a criminal offense in connection with obtaining,
attempting to obtain, or performing a private or public (federal, state, or local) transaction or
contract under a private or public transaction; violation of federal or state antitrust statutes
(including those proscribing price fixing between competitors, allocation of customers between
competitors and bid rigging) or commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements or false claims, tax evasion, obstruction of justice,
receiving stolen property or any other offense indicating a lack of business integrity or business
honesty that seriously and directly affects the participant's present responsibility;
C. are not presently indicted or otherwise criminally or civilly charged by a governmental entity
(federal, state, or local) with commission of any of the offenses enumerated in paragraph (B) of
this certification;
D. have not within a 3-year period preceding this proposal had one or more public transactions
(federal, state, or local)terminated for cause or default; and
E. has not (nor has its representative nor any person acting for the representative) (1) violated the
antitrust laws codified by Chapter 15, Texas Business & Commercial Code , or the federal antitrust
laws; or(2) directly or indirectly communicated the bid to a competitor or other person engaged in
the same line of business.
Should the respondent not be able to provide this certification (by signing the FACE PAGE Form), an
explanation should be placed after this form in the proposal response;
The respondent agrees by submitting this proposal that the respondent will include, without modification,
the certifications in subparagraphs A through E of this paragraph in all lower tier covered transactions
(i.e., transactions with subgrantees and/or contractors) and in all solicitations for lower tier covered
transactions;
21. Will comply with Title 31, USC §1352, entitled "Limitation on use of appropriated funds to influence certain
federal contracting and financial transactions," which generally prohibits recipients of federal grants and
cooperative agreements from using federal (appropriated) funds for lobbying the executive or legislative
branches of the federal government in connection with a SPECIFIC grant or cooperative agreement.
Section 1352 also requires that each person who requests or receives a federal grant or cooperative
agreement must disclose lobbying undertaken with non-federal (non-appropriated) funds. These
requirements apply to grants and cooperative agreements EXCEEDING $100,000 in total costs (45 CFR
Part 93):
A. No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned,
to any person for influencing or attempting to influence an officer or employee of any agency, a
member of Congress, an officer or employee of Congress, or an employee of a Member of
Congress in connection with the awarding of any federal contract, the making of any federal grant,
the making of any federal loan, the entering into of any cooperative agreement, and the extension,
continuation, renewal, amendment, or modification of any federal contract, grant, loan, or
cooperative agreement;
B. If any funds other than federally-appropriated funds have been paid or will be paid to any person
for influencing or attempting to influence an officer or employee of any agent, a member of
Congress, an officer or employee of Congress, or an employee of a member of Congress in
connection with this federal contract, grant, loan, or cooperative agreement, the respondent must
complete and submit Standard Form-LLL, "Disclosure of Lobbying Activities," (SF-LLL) in
accordance with its instructions. SF-LLL and continuation sheet are available upon request from
Page 69 PHC RFP#537-16-142081
the Department of State Health Services; and
C. The language of this certification must be included in the award documents for all sub-awards at
all tiers (including subcontracts, subgrants, and contracts under grants, loans and cooperative
agreements) and that all subrecipients must certify and disclose accordingly;
This certification is a material representation of fact upon which reliance was placed when this transaction
was made or entered into. Submission of this certification is a prerequisite for making or entering into this
transaction imposed by 31 USC §1352. Any person who fails to file the required certification must be
subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure;
22. Is in good standing with the Internal Revenue Service on any debt owed;
23. Affirms that no person who has an ownership or controlling interest in the organization or who is an agent
or managing employee of the organization has been placed on community supervision, received deferred
adjudication or been convicted of a criminal offense related to any financial matter, federal or state
program or felony sex crime;
24. Is in good standing with all state and/or federal departments or agencies that have a contracting
relationship with the respondent;
25. Will comply with all statutes and standards of general applicability. It is Respondent's responsibility to review
and comply with all applicable statutes, rules, regulations, executive orders and policies. Respondent will
carry out the terms of this Contract in a manner that is in compliance with the provisions set forth below.
To the extent such provisions are applicable to respondent, respondent will comply with the following:
a) The following statutes, rules, regulations and DSHS policies, and any of their subsequent amendments
that collectively prohibit discrimination on the basis of race, color, national origin, limited English
proficiency, sex, sexual orientation (where applicable), disabilities, age, substance abuse, political
belief, or religion: 1) Title VI of the Civil Rights Act of 1964, 42 U.S.C.A. §§-1 2000d et seq.; 2) Title
IX of the Education Amendments of 1972, 20 U.S.C.A. §Ili§ 1681-1683, and 1685-1686; 3)
Section 504 of the Rehabilitation Act of 1973, 29 U.S.C.A. § 794(a); 4) the Americans with
Disabilities Act of 1990, 42 U.S.C.A. §§n 12101 et seq.; 5) Age Discrimination Act of 1975, 42
U.S.C.A. §nn§ 6101-6107: 6) Comprehensive Alcohol Abuse and Alcoholism Prevention,
Treatment and Rehabilitation Act of 1970, 42 U.S.C.A. §n 290dd (b)(1); 7) 45 CFR Parts 80, 84,
86 and 91 or CFR Part 15; 8) Tex. Lab. Code, ch. 21; 9) Food Stamp Act of 1977 (7 USC §200 et
seq); 10) US Department of Labor, Equal Opportunity E.O. 11246, as amended and
supplemented; 11) Executive Order 13279 and 45 CFR Part 87 or 7 CFR Part 16 (regarding equal
treatment and opportunity for religious organizations; 12) DSHS Policy AA-5018, Non-
discrimination Policies and Procedures for DSHS Programs; and13) any other nondiscrimination
provision in specific statutes under which application for federal or state assistance is being made,
which prohibits exclusion from or limitation of participation in programs, benefits, or activities, or
denial of any aid, care, service or other benefit;
b) Drug Abuse Office and Treatment Act of 1972, 21 U.S.C.A. §§ 1101 et seq., relating to drug abuse;
c) Public Health Service Act of 1912, §§n 523 and 527, 42 U.S.C.A. §n 290dd-2, and 42 C.F.R. pt. 2,
relating to confidentiality of alcohol and drug abuse patient records;
d) Title VIII of the Civil Rights Act of 1968, 42 U.S.C.A. §§ 3601 et seq., relating to nondiscrimination in
housing;
e) Immigration Reform and Control Act of 1986, 8 U.S.C.A. § 1324a, regarding employment verification;
f) Pro-Children Act of 1994, 20 U.S.C.A. §§ 6081-6084, regarding the non-use of all tobacco products;
g) National Research Service Award Act of 1971, 42 U.S.C.A. §§n 289a-1 et seq., and 6601 (P.L. 93-
348 and P.L. 103-43), as amended, regarding human subjects involved in research;
h) Hatch Political Activity Act, 5 U.S.C.A. §§r11- 7321-26, which limits the political activity of employees
whose employment, is funded with federal funds;
Page 70 PHC RFP#537-16-142081
i) Fair Labor Standards Act, 29 U.S.C.A. §§ 201 et seq., and the Intergovernmental Personnel Act of
1970, 42 U.S.C.A. §§ 4701 et seq., as applicable, concerning minimum wage and maximum hours;
J) Tex. Gov't Code ch. 469 (Supp. 2004), pertaining to eliminating architectural barriers for persons with
disabilities;
k) Texas Workers' Compensation Act, Tex. Labor Code, chs. 401-406 28 Tex. Admin. Code pt. 2,
regarding compensation for employees' injuries;
I) The Clinical Laboratory Improvement Amendments of 1988, 42 USC § 263a, regarding the regulation
and certification of clinical laboratories;
m) The Occupational Safety and Health Administration Regulations on Blood Borne Pathogens, 29 CFR
§ 1910.1030, or Title 25 Tex. Admin Code ch. 96 regarding safety standards for handling blood borne
pathogens;
n) Laboratory Animal Welfare Act of 1966, 7 USC §§ 2131 et seq., pertaining to the treatment of
laboratory animals;
o) Environmental standards pursuant to the following: 1) Institution of environmental quality control
measures under the National Environmental Policy Act of 1969, 42 USC §§ 4321-4347 and Executive
Order 11514 (35 Fed. Reg. 4247), "Protection and Enhancement of Environmental Quality;" 2) Notification
of violating facilities pursuant to Executive Order 11738 (40 CFR Part 32), "Providing for Administration of
the Clean Air Act and the Federal Water Pollution Control Act with respect to Federal Contracts, Grants,
or Loans;" 3) Protection of wetlands pursuant to Executive Order 11990, 42 Fed. Reg. 26961; 4)
Evaluation of flood hazards in floodplains in accordance with Executive Order 11988, 42 Fed. Reg. 26951
and, if applicable, flood insurance purchase requirements of Section 102(a) of the Flood Disaster
Protection Act of 1973 (P.L. 93-234); 5) Assurance of project consistency with the approved State
Management program developed under the Coastal Zone Management Act of 1972, 16 USC §§ 1451 et
seq; 6) Conformity of federal actions to state clean air implementation plans under the Clean Air Act of
1955, as amended, 42 USC §§ 7401 et seq.; 7) Protection of underground sources of drinking water
under the Safe Drinking Water Act of 1974, 42 USC §§ 300f-300j; 8) Protection of endangered species
under the Endangered Species Act of 1973, 16 USC §§ 1531 et seq.; 9) Federal Water Pollution Control
Act, 33 USC §1251 et seq.; 10)Wild and Scenic Rivers Act of 1968 (16 U.S.C. §§ 1271 et seq.) related to
protecting certain rivers system; and 11) Lead-Based Paint Poisoning Prevention Act (42 U.S.C. §§ 4801
et seq.) prohibiting the use of lead-based paint in residential construction or rehabilitation;
p) Intergovernmental Personnel Act of 1970 (42 USC §§4278-4763 regarding personnel merit systems
for programs specified in Appendix A of the federal Office of Program Management's Standards for a
Merit System of Personnel Administration (5 C.F.R. Part 900, Subpart F);
q) Titles II and III of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of
1970 (P.L. 91-646), relating to fair treatment of persons displaced or whose property is acquired as a
result of Federal or federally-assisted programs;
r) Davis-Bacon Act (40 U.S.C. §§ 276a to 276a-7), the Copeland Act (40 U.S.C. § 276c and 18 U.S.C. §
874), and the Contract Work Hours and Safety Standards Act (40 U.S.C. §§ 327-333), regarding labor
standards for federally-assisted construction sub-agreements;
s) Assist DSHS in complying the National Historic Preservation Act of 1966, §106 (16 U.S.C. § 470),
Executive Order 11593, and the Archaeological and Historic Preservation Act of 1974 (16 U.S.C. §§
469a-1 et seq.) regarding historic property;
t) Financial and compliance audits in accordance with Single Audit Act Amendments of 1996 and OMB
Circular No. A-133, "Audits of States, Local Governments, and Non-Profit Organizations; "and
u) Requirements of any other applicable state and federal statutes, executive orders, regulations, rules,
and policies.
If this contract is funded by a grant, additional state or federal requirements found in the Notice of Grant
Award may be imposed on respondent;
26. Under §§2155.006 and 2261.053, Government Code, is not ineligible to receive a contract under this RFP
and acknowledges that any contract may be terminated and payment withheld if this certification is
inaccurate. Sections 2155.006 and 2261.053 relate to violations of federal law in connection with a
contract awarded by the federal government for relief, recovery or reconstruction efforts as a result of
Page 71 PHC RFP#537-16-142081
Hurricanes Rita or Katrina or certain other disasters;
27. Affirms that the statements in these assurances and certifications are true, accurate, and complete (to the
best of respondent's and its authorized representative's knowledge and belief), and agrees to comply with
the DSHS terms and conditions if an award is issued as a result of this proposal. Willful provision of false
information is a criminal offense. Any person making any false, fictitious, or fraudulent statement may, in
addition to other remedies available, be subject to civil penalties.
Page 72 PHC RFP#537-16-142081
APPENDIX C: HUB REQUIREMENTS
Page 73 PHC RFP#537-16-142081
HUB Subcontracting Plan (HSP) Quick Checklist
1. If all(100%)of your subcontracting opportunities will be performed using only HUB vendors,complete:
O Section 1—Respondent and Requisition Information
O Section 2 a.—Yes,I will be subcontracting portions of the contract
O Section 2 b.—List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB
vendors
O Section 2 c.—Yes
O Section 4—Affirmation
O HSPGFE Method A(Attachment A)—Complete this attachment for each subcontracting opportunity
2. If any of your subcontracting opportunities will be performed using HUB protégés,complete:
O Section 1—Respondent and Requisition Information
1 Section 2 a.—Yes,I will be subcontracting portions of the contract
O Section 2 b.—List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB proteges(Skip
Section 2 c and 2 d)
O Section 4—Affirmation
O HSP GFE Method B(Attachment B)—Complete Section B-1,Section B-2,and B-4 only for each HUB Protege subcontracting opportunity as applicable.
3. If you are subcontracting with HUB vendors and Non-HUB vendors,and the aggregate percentage*of subcontracting with HUB vendors meets or
exceeds the HUB Goal the contracting agency identified in the solicitation,complete:
1 Section 1—Respondent and Requisition Information
1 Section 2 a.—Yes,I will be subcontracting portions of the contract
O Section 2 b.—List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB vendors and Non-
HUB vendors
O Section 2 c.—No
O Section 2 d.—Yes
O Section 4—Affirmation
O HSP GFE Method A(Attachment A)—Complete this Attachment for each subcontracting opportunity.
4. If you are subcontracting with HUB vendors and/or Non-HUB vendors,and the aggregate percentage*of subcontracting with HUB vendors does not
meet or exceed the HUB Goal the contacting agency identified in the solicitation,complete:
O Section 1-Respondent and Requisition Information
O Section 2 a.-Yes,I will be subcontracting portions of the contract
O Section 2 b. -List all the portions of work you will subcontract, and indicate the percentage of the contract you expect to award to HUB vendors and Non-
HUB vendors
O Section 2 c.-No
O Section 2 d.-No
O Section 4-Affirmation
O HSP GFE Method B(Attachment B)-Complete this attachment for each subcontracting opportunity
*Aggregate percentage of the contract expected to be subcontracted to HUBs with which you have had contracts in place for five(5)years or less.
5. If you will not be subcontracting any portion of the contract and will be fulfilling the entire contract with your own resources(i.e.,equipment,supplies,
materials,and/or employees),complete:
O Section 1—Respondent and Requisition Information
O Section 2 a.—No,I will not be subcontracting any portion of the contract,and I will be fulfilling the entire contract with my own resources
O Section 3—Self Performing Justification
O Section 4—Affirmation
Page 74 PHC RFP#537-16-142081
E Q/\
uV,cr\
HUB SUBCONTRACTING PLAN (HSP)
In accordance with Texas Gov't Code §2161.252, the contracting agency has determined that subcontracting opportunities are probable under this contract.
Therefore, all respondents, including State of Texas certified Historically Underutilized Businesses (HUBs) must complete and submit this State of Texas HUB
Subcontracting Plan(HSP)with their response to the bid requisition(solicitation).
NOTE: Responses that do not include a completed HSP shall be rejected pursuant to Texas Gov't Code§2161.252(b).
The HUB Program promotes equal business opportunities for economically disadvantaged persons to contract with the State of Texas in accordance with the goals
specified in the 2009 State of Texas Disparity Study. The statewide HUB goals defined in 34 Texas Administrative Code(TAC)§20.13 are:
• 11.2 percent for heavy construction other than building contracts,
• 21.1 percent for all building construction,including general contractors and operative builders contracts,
• 32.9 percent for all special trade construction contracts,
• 23.7 percent for professional services contracts,
• 26.0 percent for all other services contracts,and
• 21 percent for commodities contracts.
- -Agency Special Instructions/Additional Requirements --
In accordance with 34 TAC §20.14(d)(1)(D)(iii), a respondent (prime contractor) may demonstrate good faith effort to utilize Texas certified HUBs for its
subcontracting opportunities if the total value of the respondent's subcontracts with Texas certified HUBs meets or exceeds the statewide HUB goal or the agency
specific HUB goal,whichever is higher.When a respondent uses this method to demonstrate good faith effort,the respondent must identify the HUBs with which it
will subcontract.If using existing contracts with Texas certified HUBs to satisfy this requirement,only contracts that have been in place for five years or less shall
qualify for meeting the HUB goal.This limitation is designed to encourage vendor rotation as recommended by the 2009 Texas Disparity Study.
SECTION 1 RESPONDENT AND REQUISITION INFORMATION
a. Respondent(Company)Name: State of Texas VID#:
Point of Contact: Phone#:
E-mail Address: Fax#:
b. Is your company a State of Texas certified HUB? ❑-Yes ❑-No
c. Requisition#: Bid Open Date:
(mmlddlyyyy)
Page 75 PHC RFP#537-16-142081
Enter your company's name here: Requisition#:
SECTION 2 SUBCONTRACTING INTENTIONS RESPONDENT
After dividing the contract work into reasonable lots or portions to the extent consistent with prudent industry practices,and taking into consideration the scope of work to be performed
under the proposed contract, including all potential subcontracting opportunities, the respondent must determine what portions of work, including goods and services, will be
subcontracted.Note:In accordance with 34 TAC§20.11.,an"Subcontractor"means a person who contracts with a prime contractor to work,to supply commodities,or to contribute
toward completing work for a governmental entity.
a. Check the appropriate box(Yes or No)that identifies your subcontracting intentions:
❑-Yes,I will be subcontracting portions of the contract.(If Yes,complete Item b,of this SECTION and continue to Item c of this SECTION.)
❑-No,I will not be subcontracting ml portion of the contract,and I will be fulfilling the entire contract with my own resources.(If No,continue to SECTION 3
and SECTION 4.)
b. List all the portions of work(subcontracting opportunities)you will subcontract.Also,based on the total value of the contract,identify the percentages of the contract you expect to
award to Texas certified HUBs,and the percentage of the contract you expect to award to vendors that are not a Texas certified HUB(i.e.,Non-HUB).
HUBs Non-HUBs
Percentage of the contract Percentage of the contract
Item# Subcontracting Opportunity Description expected to be subcontracted expected to be subcontracted Percentage of the contract
to HUBs with which you have to HUBs with which you have expected to be subcontracted
a continuous contract'in place a continuous contract'in place to non-HUBs.
for five(5)years or less. for more than five(5)years.
2
3
4
5
6 %
7
8
9
10 % %
11
12
13
14
15
Aggregate percentages of the contract expected to be subcontracted: %
(Note:If you have more than fifteen subcontracting opportunities,a continuation sheet is available online at http://window.state.tx.uslprocurementiprog/hub/hub-subcontracting-plan/)
c. Check the appropriate box(Yes or No)that indicates whether you will be using only Texas certified HUBs to perform all of the subcontracting opportunities you listed in SECTION
2,Item b.
❑-Yes(If Yes,continue to SECTION 4 and complete an"HSP Good Faith Effort-Method A(Attachment A)"for each of the subcontracting opportunities you listed.)
❑-No(If No,continue to Item d,of this SECTION.)
d. Check the appropriate box(Yes or No)that indicates whether the aggregate expected percentage of the contract you will subcontract with Texas certified HUBs with which you
have a continuous contract'in place with for five(5)years or less meets or exceeds the HUB goal the contracting agency identified on page 1 in the"Agency Special
Instructions/Additional Requirements".
❑-Yes(If Yes,continue to SECTION 4 and complete an"HSP Good Faith Effort-Method A(Attachment A)"for each of the subcontracting opportunities you listed.)
❑-No(If No,continue to SECTION 4 and complete an"HSP Good Faith Effort-Method B(Attachment B)"for each of the subcontracting opportunities you listed.)
'Continuous Contract:Any existing written agreement(including any renewals that are exercised)between a prime contractor and a HUB vendor,where the HUB vendor provides the
prime contractor with goods or service under the same contract for a specified period of time. The frequency the HUB vendor is utilized or paid during the term of the contract is not
relevant to whether the contract is considered continuous.Two or more contracts that run concurrently or overlap one another for different periods of time are considered by CPA to be
individual contracts rather than renewals or extensions to the original contract.In such situations the prime contractor and HUB vendor are entering(have entered)into"new"contracts.
Page 76 PHC RFP#537-16-142081
Enter your company's name here: Requisition#:
SECTION 2 SUBCONTRACTING INTENTIONS RESPONDENT(CONTINUATION SHEET)
a. This page can be used as a continuation sheet to the HSP Form's page 2,SECTION 2,Item b.Continue listing the portions of work(subcontracting
opportunities)you will subcontract.Also,based on the total value of the contract,identify the percentages of the contract you expect to award to Texas certified
HUBs,and the percentage of the contract you expect to award to vendors that are not a Texas certified HUB(i.e.,Non-HUB).
HUBs Non-HUBs
Percentage of the contract Percentage of the contract
Item# Subcontracting Opportunity Description expected to be subcontracted expected to be subcontracted Percentage of the contract
to HUBs with which you have to HUBs with which you have expected to be subcontracted
a continuous contract*in place a continuous contract'in place to non•HUBs.
for five(51 years or less. for more than five(51 years.
%
0/0
0/0
ok
ok
0/0
0/0
ok `Yo
%
%
%
%
%
%
%
Aggregate percentages of the contract expected to be subcontracted:
'Continuous Contract:Any existing written agreement(including any renewals that are exercised)between a prime contractor and a HUB vendor.where the HUB vendor provides the
prime contractor with goods or service under the same contract for a specified period of time. The frequency the HUB vendor is utilized or paid during the term of the contract is not
relevant to whether the contract is considered continuous.Two or more contracts that run concurrently or overlap one another for different periods of time are considered by CPA to be
individual contracts rather than renewals or extensions to the original contract.In such situations the prime contractor and HUB vendor are entering(have entered)into new contracts.
Page 77 PHC RFP#537-16-142081
Enter your company's name here: Requisition#:
SECTION 3 SELF PERFORMING JUSTIFICATION(If you responded"No"to SECTION 2,Rem a,you must complete this SECTION and continue to SECTION
4.)
Check the appropriate box(Yes or No)that indicates whether your response/proposal contains an explanation demonstrating how your company will fulfill the entire contract with its own
resources.
❑•Yes (If Yes,in the space provided below list the specific page(s)/section(s)of your proposal which explains how your company will perform the entire contract with its own
equipment,supplies,materials and/or employees.)
❑-No (If No,in the space provided below explain how your company will perform the entire contract with its own equipment,supplies,materials and/or employees.)
SECTION 4 AFFIRMATION
As evidenced by my signature below, I affirm that I am an authorized representative of the respondent listed in SECTION 1,and that the information and supporting documentation
submitted with the HSP is true and correct Respondent understands and agrees that,if awarded anv portion of the requisition:
• The respondent will provide notice as soon as practical to all the subcontractors(HUBs and Non-HUBs)of their selection as a subcontractor for the awarded contract.The notice
must specify at a minimum the contracting agency's name and its point of contact for the contract,the contract award number,the subcontracting opportunity they(the
subcontractor)will perform,the approximate dollar value of the subcontracting opportunity and the expected percentage of the total contract that the subcontracting opportunity
represents.A copy of the notice required by this section must also be provided to the contracting agency's point of contact for the contract no later than ten(10)working days after
the contract is awarded.
• The respondent must submit monthly compliance reports(Prime Contractor Progress Assessment Report—PAR)to the contracting agency,verifying its compliance with the HSP,
including the use of and expenditures made to its subcontractors(HUBS and Non-HUBS). (The PAR is available at http://www.window.state.tx.us/procuremenUprog/hub/hub-
forms/pro gressassessmentrpt.xls).
• The respondent must seek approval from the contracting agency prior to making any modifications to its HSP,including the hiring of additional or different subcontractors and the
termination of a subcontractor the respondent identified in its HSP.If the HSP is modified without the contracting agency's prior approval,respondent may be subject to any and all
enforcement remedies available under the contract or otherwise available by law,up to and including debarment from all state contracting.
• The respondent must,upon request,allow the contracting agency to perform on-site reviews of the company's headquarters and/or work-site where services are being performed
and must provide documentation regarding staffing and other resources.
Signature Printed Name Title Date
(mmlddlyyyy)
REMINDER: > If you responded"Yes"to SECTION 2,Items c or d,you must complete an"HSP Good Faith Effort-Method A(Attachment A)"for each of
the subcontracting opportunities you listed in SECTION 2,Item b.
> If you responded"No"SECTION 2,Items c and d,you must complete an"HSP Good Faith Effort-Method B(Attachment B)"for each of
the subcontracting opportunities you listed in SECTION 2,Item b.
Page 78 PHC RFP#537-16-142081
HSP Good Faith Effort - Method A (Attachment A)
IEnter your company's name here: Requisition#:
IMPORTANT:If you responded"Yes"to SECTION 2,Items c or d of the completed HSP form,you must submit a completed"HSP Good Faith Effort-Method A
(Attachment A)" for each of the subcontracting opportunities you listed in SECTION 2, Item b of the completed HSP form. You may photo-copy this page or
download the form at http://www.window.state.tx.us/procurement/prog/hub/hub-forms/HUBSubcontractingPlanAttachment-A.doc
SECTION A.1 SUBCONTRACTING OPPORTUNITY
Enter the item number and description of the subcontracting opportunity you listed in SECTION 2, Item b,of the completed HSP form for which you are completing
this attachment.
Item#: Description:
SECTION A-2 SUBCONTRACTOR SELECTION
List the subcontractor(s)you selected to perform the subcontracting opportunity you listed above in SECTION A-1. Also identify whether they are a Texas certified HUB and their VID
number,the approximate dollar value of the work to be subcontracted,the expected percentage of work to be subcontracted,and indicate whether the company is a Texas certified HUB.
Company Name Texas VID# Approximate Expected Percentage
certified HUB (Required if Texas Dollar Amount of Contract
certified HUB)
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $ %
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $ %
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $ %
❑-Yes ❑-No $ %
❑-Yes ❑-No $ %
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $ %
❑-Yes ❑-No $
REMINDER:As specified in SECTION 4 of the completed HSP form,if you(respondent)are awarded any portion of the requisition,you are required to provide notice as soon as
practical to all the subcontractors(HUBs and Non-HUBs)of their selection as a subcontractor.The notice must specify at a minimum the contracting agency's name and its point of
contact for the contract,the contract award number,the subcontracting opportunity they(the subcontractor)will perform,the approximate dollar value of the subcontracting opportunity
and the expected percentage of the total contract that the subcontracting opportunity represents.A copy of the notice required by this section must also be provided to the contracting
agency's point of contact for the contract no later than ten(10)working days after the contract is awarded.
Page 79 PHC RFP#537-16-142081
HSP Good Faith Effort - Method B (Attachment B)
IEnter your company's name here: Requisition#:
IMPORTANT:ff you responded"No"to SECTION 2,Items c and d of the completed HSP form,you must submit a completed"HSP Good Faith Effort-Method B(Attachment B)"for
each of the subcontracting opportunities you listed in SECTION 2, Item b of the completed HSP form. You may photo-copy this page or download the form at
http:llwww.window.state.tx.uslprocu rement/proglhu blhub-forms/HUBSubcontractingPlanAttachment-B.doc
SECTION B-1 SUBCONTRACTING OPPORTUNITY
Enter the item number and description of the subcontracting opportunity you listed in SECTION 2,Item b,of the completed HSP form for which you are completing this attachment.
Item#: Description:
SECTION B-2 MENTOR PROTEGE PROGRAM
If respondent is participating as a Mentor in a State of Texas Mentor Protégé Program,submitting its Protege(Protege must be a State of Texas certified HUB)as a subcontractor to
perform the subcontracting opportunity listed in SECTION B-1,constitutes a good faith effort to subcontract with a Texas certified HUB towards that specific portion of work.
Check the appropriate box(Yes or No)that indicates whether you will be subcontracting the portion of work you listed in SECTION B-1 to your Protege.
0-Yes(If Yes,to continue to SECTION B-4.)
0-No 1 Not Applicable(If No or Not Applicable,continue to SECTION B-3 and SECTION B-4.)
SECTION B-3 NOTIFICATION OF SUBCONTRACTING OPPORTUNITY
When completing this section you MUST comply with items a,b,c and d,thereby demonstrating your Good Faith Effort of having notified Texas certified HUBs and minority or women
trade organizations or development centers about the subcontracting opportunity you listed in SECTION B-1.Your notice should include the scope of work,information regarding the
location to review plans and specifications, bonding and insurance requirements,required qualifications,and identify a contact person.When sending notice of your subcontracting
opportunity, you are encouraged to use the attached HUB Subcontracting Opportunity Notice form, which is also available online at
http:llwww.window.state.tx.uslprocurementlprog/hublh ub-subcontracting-plan!
Retain supporting documentation(i.e.,certified letter, fax, e-mail)demonstrating evidence of your good faith effort to notify the Texas certified HUBs and minority or women trade
organizations or development centers.Also,be mindful that a working day is considered a normal business day of a state agency,not induding weekends,federal or state holidays,or
days the agency is declared closed by its executive officer. The initial day the subcontracting opportunity notice is sent/provided to the HUBs and to the minority or women trade
organizations or development centers is considered to be"day zero"and does not count as one of the seven(7)working days.
a. Provide written notification of the subcontracting opportunity you listed in SECTION B-1,to three(3)or more Texas certified HUBs.Unless the contracting agency specified a
different time period,you must allow the HUBs at least seven(7)working days to respond to the notice prior to your submitting your bid response to the contracting agency.When
searching for Texas certified HUBs,ensure that you use the State of Texas'Centralized Master Bidders List(CMBL)and Historically Underutilized Business(HUB)Search directory
located at http:llwww.window.state.tx.uslprocurement/Icmbllcmblhub.html.HUB Status code"A"signifies that the company is a Texas certified HUB.
b. List the three(3)Texas certified HUBs you notified regarding the subcontracting opportunity you listed in SECTION B-1.Include the company's Vendor ID(VID)number,the date
you sent notice to that company,and indicate whether it was responsive or non-responsive to your subcontracting opportunity notice.
Company Name VID# Date Notice Sent Did the HUB Respond?
(mm/dd/yyyy)
❑-Yes ❑-No
❑-Yes ❑-No
❑-Yes ❑-No
c. Provide written notification of the subcontracting opportunity you listed in SECTION B-1 to two(2)or more minority or women trade organizations or development centers in Texas
to assist in identifying potential HUBs by disseminating the subcontracting opportunity to their members/participants.Unless the contracting agency specified a different time period,
you must provide your subcontracting opportunity notice to minority or women trade organizations or development centers at least seven(7)working days prior to submitting your
bid response to the contracting agency.A list of trade organizations and development centers that have expressed an interest in receiving notices of subcontracting opportunities is
available on the Statewide HUB Program's webpage at http:llwww.window.state.tx.uslprocurementlproglhublmwb-links-1!
d. List two(2)minority or women trade organizations or development centers you notified regarding the subcontracting opportunity you listed in SECTION B-1.Include the date when
you sent notice to it and indicate if it accepted or rejected your notice.
Minority/Women Trade Organizations or Development Centers Date Notice Sent Was the Notice Accepted?
(mm/ddlyyyy)
❑-Yes ❑-No
❑-Yes ❑-No
Page 80 PHC RFP#537-16-142081
HSP Good Faith Effort - Method B (Attachment B) cont.
Enter your company's name here: Requisition#:
SECTION B-4 SUBCONTRACTOR SELECTION
a. Enter the item number and description of the subcontracting opportunity for which you are completing this Attachment B continuation page.
Item#: Description:
b. List the subcontractor(s)you selected to perform the subcontracting opportunity you listed in SECTION B-1. Also identify whether they are a Texas certified HUB
and their VID number,the approximate dollar value of the work to be subcontracted,the expected percentage of work to be subcontracted,and indicate whether the
company is a Texas certified HUB.
Company Name Texas VID# Approximate Expected Percentage
certified HUB (Required if Texas Dollar Amount of Contract
certified HUB)
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $
❑-Yes ❑-No $ %
c. If any of the subcontractors you have selected to perform the subcontracting opportunity you listed in SECTION B-1 is not a Texas certified HUB,provide written
justification for your selection process(attach additional page if necessary):
REMINDER:As specified in SECTION 4 of the completed HSP form,if you(respondent)are awarded any portion of the requisition,you are required to provide notice as soon as practical
to all the subcontractors(HUBs and Non-HUBS)of their selection as a subcontractor.The notice must specify at a minimum the contracting agency's name and its point of contact for the
contract, the contract award number, the subcontracting opportunity it(the subcontractor)will perform, the approximate dollar value of the subcontracting opportunity and the expected
percentage of the total contract that the subcontracting opportunity represents.A copy of the notice required by this section must also be provided to the contracting agency's point of contact
for the contract no later than ten(10)working days after the contract is awarded.
Page 81 PHC RFP#537-16-142081
51
Y01 HUB SubcontractingOpportunity Notification Form
pp Y
In accordance with Texas Gov't Code,Chapter 2161,each state agency that considers entering into a contract with an expected value of$100,000 or more shall,before the
agency solicits bids,proposals,offers,or other applicable expressions of interest,determine whether subcontracting opportunities are probable under the contract.The state
agency I have identified below in Section B has determined that subcontracting opportunities are probable under the requisition to which my company will be responding.
34 Texas Administrative Code,§20.14 requires all respondents(prime contractors)bidding on the contract to provide notice of each of their subcontracting opportunities to at
least three(3)Texas certified HUBs(who work within the respective industry applicable to the subcontracting opportunity), and allow the HUBs at least seven(7)working
days to respond to the notice prior to the respondent submitting its bid response to the contracting agency, In addition,the respondent must provide notice of each of its
subcontracting opportunities to two(2)or more minority or women trade organizations or development centers at least seven (7)working days prior to submitting its bid
response to the contracting agency.
We respectfully request that vendors interested in bidding on the subcontracting opportunity scope of work identified in Section C,Item 2,reply no later than the date and
time identified in Section C,Item 1.Submit your response to the point-of-contact referenced in Section A.
Section A PRIME CONTRACTOR'S INFORMATION
Company Name: State of Texas VID#:
Point-of-Contact: Phone#:
E-mail Address: Fax#:
Section B CONTRACTING STATE AGENCY AND REQUISITION INFORMATION
Agency Name:
Point-of-Contact: Phone#:
Requisition#: Bid Open Date:
Section C SUBCONTRACTING OPPORTUNITY RESPONSE DUE DATE,DESCRIPTION,REQUIREMENTS AND RELATED INFORMATION
If you would like for our company to consider your company's bid for the subcontracting opportunity identified below in Item 2,
we must receive your bid response no later than Central Time on:
1. Potential
Subcontractor's Bid In accordance with 34 TAC§20.14,each notice of subcontracting opportunity shall be provided to at least three(3)Texas certified HUBs,and allow the HUBs at least seven(7)
working days to respond to the notice prior to submitting our bid response to the contracting agency.In addition,we must provide the same notice to two(2)or more minority or women
Response Due Date: trade organizations or development centers at least seven(7)working days prior to submitting our bid response to the contracting agency.
(A working day is considered a normal business day of a state agency,not including weekends,federal or state holidays,or days the agency is declared dosed by its executive officer.
The initial day the subcontracting opportunity notice is sent/provided to the HUBS g to the minority or women trade organizations or development centers is considered to be'day
zero'and does not count as one of the seven(7)working days.)
2.Subcontracting
Opportunity
Scope of Work:
3. Required
Qualifications:
❑-Not Applicable
4. Bondingllnsurance
Requirements:
❑-Not Applicable
5. Location to review
plans/specifications:
❑-Not Applicable
Page 82 PHC RFP#537-16-142081
Attachment H — Grantee's FY2018 & FY2019
Renewal Application
TEXASDepartment of Health and Human Services Commission
v V; Health and Human FORM A: FACE PAGE
'sem, 7' Services
Primary Health Care Renewal for Financial Assistance
This form requests basic information about the respondent and project,including the signature of the authorized representative. The face page
is the cover page of the proposal and must be completed in its entirety.
RESPONDENT INFORMATION
1) LEGAL BUSINESS NAME: City of Port Arthur
2) MAILING Address Information(include mailing address,street,city,county,state and zip code): Check if address change 0
449 Austin Avenue
Port Arthur,TX 77640
3) PAYEE Name and Mailing Address(if different from above): Check if address change 0
Same as above
4) Federal Tax ID No.(9 digit),State of Texas Comptroller Vendor ID No.(14 digit)or Social Security 17460018850011
Number(9 digit):
*The respondent acknowledges,understands and agrees that the respondent's choice to use a social security number as the vendor identification
number for the contract may result in the social security number being made public via state open records requests.
5)Medicaid Provider Number.133353608 OR Date Medicaid Application Submitted&TMHP Ticket#:
6)DUNS Number:137134909
7) TYPE OF ENTITY(check all that apply):
xxrc;J City ❑ Nonprofit Organization* 0 Individual
O County 0 For Profit Organization* ❑ FQHC
0 Other Political Subdivision 0 HUB Certified 0 State Controlled Institution of Higher Learning
❑ State Agency 0 Community-Based Organization 0 Hospital
O Indian Tribe ❑ Minority Organization 0 Private
❑ Faith Based(Nonprofit Org) ❑ Other(specify):
'If incorporated,provide 10-digit charter number assigned by Secretary of State:
8) PROPOSED BUDGET AND PERIOD: $70,000 Start Date: September 1, 2017 End Date: August 31,2018
9) PROPOSED BUDGET AND PERIOD: $70,000 Start Date: September 1, 2018 End Date: August 31,2019
10) COUNTIES SERVED BY PROJECT: See attached list.Include completed Form A-1 behind Form A: Face Page
11)PHC PROJECT CONTACT PERSON
Name: udith A.Smith,RN BSN
Phone: 09-983-8832
Fax: 09-983-1530
E-mail: udith.smith@portarthurtx.gov
12) FINANCIAL OFFICER •
Name: Rosie Vela,CGFO/CPA
Phone. 409-983-8174
Fax: 409-984-5463
E-mail: rosie.vela@portarthurtx.gov
The facts affirmed by me in this proposal are truthful and I warrant the respondent is in compliance with the assurances and certifications contained in HHSC
Assurances and Certifications. I understand the truthfulness of the facts affirmed herein and the continuing compliance with these requirements are conditions
precedent to the award of a contract. This document has been duly authorized by the governing body of the respondent and I(the person signing below)am
authorized to represent the respondent
13)AUTHORIZED REPRESENTATIVE Check if change fl 14) SIGNATURE
`OF AUTHORIZED REPRESENTATIVE
Name: Judith A.Smith,RN,BSN u,, 4) v aFKA: Rfl & /
Title: Director of Health Services
Phone: 409-983-8832 15 DATE
Fax: 409-983-1530
E-mail: :udith.smith@portarthurtx gov bN/i 81g011'
Page 1 FY18 and FY19 PHC Renewal
FORM A-1: TEXAS COUNTIES AND REGIONS LIST (in alphabetical order)
Legal Business Name of
Respondent:
COUNTIES SERVED BY PROJECT-Item 9 of Form A:Face Page:Check 0 counties to be served and include behind Form A:Face Page.
Counties 0 R Counties 0 R Counties 0 R Counties 0 R Counties 0 R
-A- Crosby 0 01 Hays 0 07 Martin 0 09 Schleicher 0 09
Anderson 0 04 Culberson ❑ 10 Hemphill 0 01 Mason 0 09 Scurry 0 02
Andrews 0 09 -D- Henderson 0 04 Matagorda 0 06 Shackelford ❑ 02
Angelina 0 05 Dallam ❑ 01 Hidalgo 0 11 Maverick 0 08 Shelby ❑ 05
Aransas ❑ 11 Dallas 0 03 Hill 0 07 McCulloch 0 09 Sherman ❑ 01
Archer ❑ 02 Dawson ❑ 09 Hockley ❑ 01 McLennan 0 07 Smith ❑ 04
Armstrong ❑ 01 Deaf 0 01 Hood ❑ 03 McMullen 0 11 Somervell 0 03
Smith
Atascosa 0 08 Delta ❑ 04 Hopkins 0 04 Medina 0 08 Starr 0 11
Austin 0 06 Denton 0 03 Houston 0 05 Menard 0 09 Stephens 0 02
-B- DeWitt ❑ 08 Howard 0 09 Midland 0 09 Sterling 0 09
Bailey 0 01 Dickens 0 01 Hudspeth 0 10 Milam 0 07 Stonewall ❑ 02
Bandera ❑ 08 Dimmit 0 08 Hunt 0 03 Mills 0 07 Sutton ❑ 09
Bastrop ❑ 07 Donley ❑ 01 Hutchinson ❑ 01 Mitchell ❑ 02 Swisher ❑ 01
Baylor ❑ 02 Duval ❑ 11 -I- Montague ❑ 02 -T-
Bee El 11 -E- Inion ❑ 09 Montgomery ❑ 06 Tarrant ❑ 03
Bell ❑ 07 Eastland ❑ 02 -J- Moore ❑ 01 Taylor 0 02
Bexar ❑ 08 Ector ❑ 09 Jack 0 02 Morris 0 04 Terrell El 09
Blanco ❑ 07 Edwards ❑ 08 Jackson ❑ 08 Motley ❑ 01 Terry 0 01
Borden ❑ 09 Ellis ❑ 03 Jasper 0 05 -N- Throckmorton ❑ 02
Bosque ❑ 07 El Paso ❑ 10 Jeff Davis ❑ 10 Nacogdoches ❑ 05 Titus El 04
Bowie ❑ 04 Erath C 03 Jefferson ❑ 05 Navarro ❑ 03 Tom Green ❑ 09
Brazoria ❑ 06 -F- Jim Hogg 0 11 Newton ❑ 05 Travis ❑ 07
Brazos ❑ 07 Falls 0 07 Jim Wells ❑ 11 Nolan ❑ 02 Trinity 0 05
Brewster ❑ 10 Fannin ❑ 03 Johnson 0 03 Nueces 0 11 Tyler 0 05
Briscoe ❑ 01 Fayette ❑ 07 Jones 0 02 -0- -U-
Brooks ❑ 11 Fisher ❑ 02 -K- Ochiltree 0 01 Upshur El 04
Brown ❑ 02 Floyd ❑ 01 Karnes ❑ 08 Oldham 0 01 Upton ❑ 09
Burleson 0 07 Foard ❑ 02 Kaufman ❑ 03 Orange ❑ 05 Uvalde 0 08
Burnet ❑ 07 Fort Bend ❑ 06 Kendall ❑ 08 -p- -V-
-C- Franklin ❑ 04 Kenedy ❑ 11 Palo Pinto 0 03 Val Verde ❑ 08
Caldwell ❑ 07 Freestone 0 07 Kent ❑ 02 Panola 0 04 Van Zandt ❑ 04
Calhoun 0 08 Frio 0 08 Kerr ❑ 08 Parker ❑ 03 Victoria ❑ 08
Callahan ❑ 02 -G- Kimble 0 09 Parmer ❑ 01 -W-
Cameron ❑ 11 Gaines ❑ 09 King ❑ 01 Pecos ❑ 09 Walker 0 06
Camp ❑ 04 Galveston ❑ 06 Kinney ❑ 08 Polk ❑ 05 Waller ❑ 06
Carson ❑ 01 Garza 0 01 Kleberg ❑ 11 Potter ❑ 01 Ward 0 09
Cass ❑ 04 Gillespie 0 08 Knox ❑ 02 Presidio 0 10 Washington 0 07
Castro ❑ 01 Glasscock ❑ 09 -L- -R- Webb ❑ 11
Chambers ❑ 06 Goliad ❑ 08 Lamar ❑ 04 Rains 0 04 Wharton ❑ 06
Cherokee ❑ 04 Gonzales 0 08 Lamb 0 01 Randall ❑ 01 Wheeler ❑ 01
Childress ❑ 01 Gray 0 01 Lampasas 0 07 Reagan ❑ 09 Wichita ❑ 02
Clay ❑ 02 Grayson 0 03 La Salle 0 08 Real ❑ 08 Wilbarger 0 02
Cochran 0 01 Gregg 0 04 Lavaca ❑ 08 Red River ❑ 04 Willacy ❑ 11
Coke ❑ 09 Grimes ❑ 07 Lee ❑ 07 Reeves ❑ 09 Williamson 0 07
Coleman ❑ 02 Guadalupe ❑ 08 Leon ❑ 07 Refugio ❑ 11 Wilson 0 08
Collin ❑ 03 -H- Liberty 0 06 Roberts ❑ 01 Winkler ❑ 09
Collingsworth ❑ 01 Hale 0 01 Limestone 0 07 Robertson ❑ 07 Wise 0 03
Colorado ❑ 06 Hall 0 01 Lipscomb ❑ 01 Rockwall ❑ 03 Wood ❑ 04
Comal 0 08 Hamilton 0 07 Live Oak ❑ 11 Runnels 0 02 -Y-
Comanche ❑ 02 Hansford ❑ 01 Llano 0 07 Rusk ❑ 04 Yoakum 0 01
Concho ❑ 09 Hardeman ❑ 02 Loving 0 09 -S- Young ❑ 02
Cooke ❑ 03 Hardin ❑ 05 Lubbock 0 01 Sabine 0 05 -Z-
Coryell ❑ 07 Harris ❑ 06 Lynn 0 01 San ❑ 05 Zapata ❑ 11
Augustine
Cottle ❑ 02 Harrison ❑ 04 -M- San Jacinto ❑ 05 Zavala ❑ 08
Crane ❑ 09 Hartley ❑ 01 Madison 0 07 San Patricio 0 11
Crockett 0 09 Haskell 0 02 Marion ❑ 04 San Saba ❑ 07
Page 3 FY18 and FY19 PHC Renewal
FORM B: CONTACT PERSON INFORMATION
Legal Business
Name of
Respondent: CITY OF PORT ARTHUR
This form provides information about the appropriate contacts in the respondent's organization in addition to those on FORM A:
FACE PAGE. Complete all information for all contacts within your agency.Mark N/A if a contact does not apply to your
agency.*All phone numbers should be a direct line to the designated individual.*if any of the following information changes
during the term of the contract,please send written notification to the Contract Manager in the Contract Management Unit.
*Please ensure that all information is complete and accurate.*
End ia James
Contact: Mailing Address(incl.street,city,county,state,&zip):
Title: Eligibility/Billing Clerk 449 Austin Avenue
Phone: 409-983-8896 Port Arthur,TX,Jefferson,TX, 77640
Fax: 409-933-1530
Email: endia.james@portarthurtx.gov
Contact: Judith Smith, RN, BSN Mailing Address(incl.street,city,county,state,&zip):
Title: Director of Health Same as above
Phone: 409-983-8832
Fax: 409-983-1530
Email: judith.smith@portarthurtx.gov
Contact: Latasha Mayon, RN, BSN Mailing Address(incl.street,city,county,state,&zip):
Title: Assistant Director of Health Same as above
Phone: 409-983-8862
Fax: 409-984-9093
Email: Latasha.mayon@portarthurtx.
:nu
Erika Flores
Contact: Mailing Address(incl.street,city,county,state,&zip):
Title: Administrative Aide II Same as above
Phone: 409-983-8864
Fax: 409-983-5012
Email: Erika.flores@portarthurtx.gov
Contact: Dr. William George, MD Mailing Address(incl.street,city,county,state,&zip):
Title: Health Authority Same as above
Phone: 409-983-8878
Fax: 409-983-1530
Email: WGEORGEMD@gt.rr.com
Page 4 FY18 and FY19 PHC Renewal
FORM E: FY18 AND FY19 PERFORMANCE MEASURES
Contractor must include the performance measures for FY18 and FY19 budgets. The proposed target
levels of performance may be negotiated and agreed upon by the contractor and HHSC. In the event a
contract is awarded, respondent agrees that this performance measure will be used to assess, in part,the
contractor's effectiveness in providing Primary Health Care (PHC) services described. The performance
measure is included in the contractor's statement(s) of work, and HHSC expects that by the end of the
contract period the contractor will have met it.
Instructions: Using the information below, calculate cost per client and complete each table.
PHC performance measures are the estimated total number of unduplicated PHC clients to whom
the respondent will provide services at the proposed HHSC funded clinic sites. This total should be
a reasonable estimate of the number of unduplicated clients the respondent can serve, based on
the average cost per client. These performance measures will be included in the PHC contract.
For FY18 and FY19, estimate the average cost per epilepsy client based on projected services. If
the respondent has not determined an average cost per client for the proposed project, the
statewide average of$180 may be used. If respondent's cost per client exceeds $180 per client,
respondent must provide an explanation and justification (below)for the cost.
Calculate total number of unduplicated clients to whom the respondent will provide services during
the contract period with HHSC funds and multiply by the average cost per client to determine the
total dollar amount.
The total amount of PHC funding must be the same dollar amount as the total amount of
PHC funding on Form A: Face Page, line#8 and line#9.
FY 2018 Budget
Total Number of Unduplicated PHC Clients /Average Cost per Client/Total Amount
Total#Unduplicated HHSC Average Cost per Client #Clients x Total Average
AmCot t/Client=
Clients
$175 $70,000
4UU
FY 2019 Budget
Total Number of Unduplicated PHC Clients /Average Cost per Client/Total Amount
Total#Unduplicated HHSC Average Cost per Client #Clients x Average Cost/Client=
Clients Total Amount
400 $175 $70,000
Provide explanation/justification if over $180 cost per client:
FORM I: PHC CLINIC SITES
Legal Business Name of Contractor: CITY OF PORT ARTHUR Clinic Site # 1
of 1
Instructions: CLINIC SITE INFORMATION: Complete this form for EACH clinic site that will provide
PHC services September 1St for FY18 and FY19. Information provided in the below table will be
displayed In the HHSC Clinic Locator.
*Please ensure that all information is accurate.*
Clinic Name: CITY OF PORT ARTHUR
Street Address:449 Austin Avenue Suite:
City: Port Arthur Count •Jeff Zip Code: 77640 HSR: 6/5S
v:Jeff
Clinic APPOINTMENT Phone#:409-983-8896
Clinic PRIMARY Phone#:409-983-8886 Fax:409-983-1530
Service Area
(counties to be served Jefferson
by this clinic site):
Contact Person:Judith Smith, RN, BSN
Pharmacy License#: 7078 Class: TPI#: 133353608 NPI#: 1518157122
Subcontractor Site: ❑ No
Mobile Site: ❑ [ No
CLINIC HOURS
DAY HOURS OF OPERATION #MONTHLY CLINICS
Morning Afternoon Evening(after 5pm)
From To From To From To
MONDAY 8:00 12:00 1:00 5:00 N/A N/A 4
TUESDAY 8:00 12:00 1:00 5:00 N/A N/A 4
WEDNESDAY 8:00 12:00 1:00 5:00 N/A N/A 4
THURSDAY 8:00 12:00 1:00 5:00 N/A N/A 4
FRIDAY 8:00 12:00 1:00 5:00 N/A N/A 4
SATURDAY
SUNDAY
TOTAL HRS/MONTH 160
TOTAL 20
CLINICS/MONTH
Primary Health Care Program
FORM J: FY18 PRIMARY HEALTH CARE (PHC) PROGRAM CERTIFICATION
This certification pertains to the following Primary Health Care Program Applicant:
Applicant's Name City of Port Arthur
Federal Tax ID Number 746001885
NPI Number 1518157122
Applicant's primary billing address:
Street Address 449 Austin Avenue
Street Address City/State/Zip Code 77640
Telephone Number 409-983-8896
Applicant's primary physical address:
Street Address 449 Austin Avenue
DEFINITIONS
For the purposes of this certification,the following terms are defined as follows:
The term 'Affiliate"means:
An individual or entity that has a legal relationship with another entity,which relationship Is created or
governed by at least one written instrument that demonstrates:
1. common ownership,management,or control;a franchise;or
2. the granting or extension of a license or other agreement that authorizes the Affiliate to use the
other entity's brand name,trademark,service mark,or other registered identification mark.
The"written instruments"referenced above may include a certificate of formation,a franchise agreement,
standards of affiliation,bylaws,articles of incorporation,or a license,but do not include agreements
related to a physician's participation in a physician group practice,such as a hospital group agreement,
, staffing agreement,management agreement,or collaborative practice agreement
The term "Promote"means advancing,furthering,advocating,or popularizing Elective Abortion by,for
example:
1. taking affirmative action to secure Elective Abortion services for a Primary Health Care Program
Client(such as making an appointment,obtaining consent for the Elective Abortion,arranging for
transportation,negotiating a reduction in an Elective Abortion provider fee,or arranging or
scheduling an Elective Abortion procedure); however,the term does not include providing upon
the patient's request neutral,factual information and nondirective counseling,including the name,
address,telephone number,and other relevant information about a provider;
2. furnishing or displaying to a Primary Health Care Program Client Information that publicizes or
advertises an Elective Abortion service or provider;or
3. using,displaying,or operating under a brand name,trademark,service mark,or registered
identification mark of an organization that performs or Promotes Elective Abortions.
Primary Health Care Program
My name is Judith A. Smith, RN, BSN . lam the provider or,if the provider is
an organization, I am the provider's Director of Health Services (title or
position) 1 am of sound mind, capable of making this certification, and 1 am personally
acquainted with the facts stated here. If 1 am representing an organizational provider, I am
authorized to make this certification on the provider's behalf. Throughout the remainder of
this document, the word"I"will represent the individual provider that is completing this
form or the organizational provider on whose behalf the form is being completed. If this
form is being completed on behalf of an organizational provider, the word "1"is inclusive of
the organization, owners, officers, employees,and volunteers, or any combination of these.
i understand that the Texas Legislature has specified that Primary Health Care Program
funds may not be used to pay the direct or Indirect Costs of abortion procedures provided
by HHSC contractors, or distributed to individuals or entities that perform Elective Abortion
procedures or that contract with or provide funds to individuals or entities for the
performance of Elective Abortion procedures. Accordingly, consistent with the legislative
requirement found under Article Ii, Rider 63(relating to the Primary Health Care Program) of
the General Appropriations Act(H.B. 1, 84th Legislature, Regular Session, 2015, art. ll, at
11-63).
I understand that i am not qualified to participate in the PHC program or to bill the program
for services if I, or any my organization's subcontractors, perform or promote elective
abortions or if I, or any my organization's subcontractors, are an affiliate of an entity that
performs or promotes elective abortions.
By checking the boxes under each statement below, l affirm that each of the following
statements is true. i understand that my failure to mark each of the statements will be
regarded as my representation that the statement is false:
1. I do not, nor do any of my organization's subcontractors, perform or Promote Elective Abortions
outside the scope of the Primary Health Care Program.
o I affirm that this statement is true and correct.
2. I am not, nor are any of my organization's subcontractors, an Affiliate, as defined on p. 2 of this
document, of an entity that performs or Promotes Elective Abortions. Furthermore, my
organization, and any of my organization's subcontractors, are legally separate entities from
entities that perform or Promote Elective Abortions.
I affirm that this statement is true and correct.
3. In offering or performing a Primary Health Care Program service, I do not, nor do any of my
organization's subcontractors, perform or Promote Elective Abortions within the scope of the
Primary Health Care Program.
O I affirm that this statement is true and correct.
4. In offering or performing a Primary Health Care Program service, I, as well as my
organization's subcontractors, maintain physical and financial separation between any Primary
Health Care Program activities and any Elective Abortion-performing or abortion-promoting
activity, in particular:
a. All Primary Health Care Program services are physically separated from any Elective
Abortion activities, no matter what entity is responsible for the activities;
b. The governing board or other body that controls me, or any of my organization's
subcontractors, does not have any board members who are also members of the governing
board of an entity that performs or Promotes Elective Abortions;
c. None of the funds that I, or any of my organization's subcontractors, receive for performing
Primary Health Care Program services are used to directly or indirectly support
Primary Health Care Program
the performance or promotion of Elective Abortions by an Affiliate, and my, and any of my
organization's subcontractors', accounting records can confirm this;
d. My organization does not, nor do any of my organization's subcontractors, transfer any
funds, through gift or payment, to an entity that performs or Promotes Elective Abortions.
My organization and my organization's subcontractors do not share expenses or costs
(including overhead, rent, phone, equipment, or utilities)with an entity that performs or
Promotes Elective Abortions;
e. I do not, nor do any of my organization's subcontractors, display any signs or materials
that Promote Elective Abortion at any locations or in any public electronic communications.
f Any employee employed by my organization, or any my organization's subcontractors, is
not also employed by an entity that performs or Promotes Elective Abortions.
71 I affirm that this statement is true and correct.
5. I do not, nor do any of my organization's subcontractors, use, display, or operate under a brand
name, trademark, service mark, or registered identification mark of an organization that
performs or Promotes Elective Abortions,
0 I affirm that this statement is true and correct.
6. I cannot affirm that the statements 1-5 above are"true and correct," but I do affirm all of the
following: I do not perform Elective Abortions; none of the funds that I, or any of my
organization's subcontractors, receive (or will receive) for performing Primary Health Care
Program services are (or will be) used to directly or indirectly support the performance of
Elective Abortions, and my accounting records can confirm this; my organization does not, nor
do any of my organization's subcontractors, transfer any Primary Health Care Program funds,
through gift or payment, to an entity for the performance of Elective Abortions; and I comply with
all of the requirements of(H.B. 1, 84th Legislature, Regular Session, 2015, art. II, at 11-63), if
applicable.
y I affirm That this statement is true and correct.
In addition, I understand and acknowledge that:
1. If I fail to complete and submit this certification, I will be disqualified from the Primary Health Care
Program and the Texas Health and Human Services Commission (HHSC)(henceforth, "HHSC")will
deny any claims I submit for Family Planning Program services.
2. If, after I submit this signed certification, I, or any my organization's subcontractors, perform or
agree to perform, or Promote Elective Abortions, I will notify HHSC at least 30 calendar days
before such action is taken. If I fail to notify HHSC as required, I will be disqualified from the HHSC
Program and HHSC will deny any claims I submit for Primary Health Care Program services.
3. If, while participating in the Primary Health Care Program, I, or any of my organization's subcontractors,
perform or Promote an Elective Abortion, I will be disqualified from the Primary Health Care
Program, and HHSC will deny any claims I submit for Family Planning Program services.
4. If I submit this certification and agree to its terms, but HHSC determines that I am in fact ineligible to
participate in the Primary Health Care Program, HHSC may place a payment hold on claims
submitted by me or my organization for Primary Health Care Program services until HHSC can
make a final determination regarding my eligibility.
5. If HHSC determines that I am ineligible to receive funds under the Primary Health Care Program:
a) HHSC may recoup Primary Health Care Program funds paid on claims that I have incurred since
the date the provider became ineligible;
b) HHSC will deny all Primary Health Care Program claims that I have submitted since the date of
ineligibility;and
c) I will remain ineligible to participate in the Primary Health Care Program until I comply with the
provisions of this certification form.
If I knowingly make a false statement or misrepresentation on this certification, HHSC may consider me
to have committed fraud or tampered with a government record under the laws of Texas, and I may be
excluded from participation in the HHSC Program.
Primary Health Care Program
If statements 1-5 are, or alternatively statement 6 is, marked"true,"the effective dates of your
certification are as follows: (The effective date of the Certification spans from the contract start
date through the end of the contract/project year.)
Effective Date of Certification: 09/01/2017 through 08/31/2018.
Note: Each Applicant must complete a new certification form for each contract renewal and provide it
to HHSC prior to execution of a Primary Health Care Program contract. The certification form will be
provided to Applicants and/or contractors as a part of the contracting packet.
If, after certification, you can no longer affirm that any of statements 1- 5 are, or alternatively
6 is, true, you must request an immediate termination of your Primary Health Care Program
certification.
Signature:
TAtiatb 114/ .(Alt AN 1366)
Printed Name:
Title: `, gfa� v SvYaca
J i0U1eC� (np
Date: O4 ji7
Attachment I — Supplemental Conditions
ATTACHMENT I
SUPPLEMENTAL CONDITIONS
The Uniform Terms and Conditions- Grant,Version 2.14,Attachment C to this Contract,
are hereby revised as follows:
A. Section 2.04,Debt to State and Corporate Status,is deleted in its entirety and replaced
with the following:
2.04 Debt to State and Corporate Status. Omitted.
B. Section 2.05,Application of Payment Due, is deleted in its entirety and replaced with the
following:
2.05 Application of Payment Due. Omitted.
C. Section 9.02 Insurance is deleted in its entirety and replaced with the following:
Section 9.02 Insurance
Pursuant to Chapter 2259 of the Texas Government Code entitled, "Self-Insurance by
Governmental Unity," each Party is self-insured and,therefore, is not required to purchase
insurance.
D. Section 9.05,Indemnity,is hereby amended by adding the following:
System Agency acknowledges that Grantee has been organized pursuant to the Constitution
and laws of the State of Texas,possesses certain rights and privileges, is subject to certain
limitations and restrictions, and only has such authority as is granted to it under the
Constitution and laws of the State of Texas.No provision of this Contract extends Grantee's
liability beyond the liability or authority provided in the Constitution and the laws of the
State of Texas.
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