HomeMy WebLinkAboutPR 20975: TO AMEND THE CONTRACT WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIMARY HEALTH CARE PROGRAM AND THE CITY OF PORT ARTHUR Enern
City of City
410/
% ort rthu^��
Texas
Date: July 23, 2019
To: Rebecca Underhill, Interim City Manager
From: Judith A. Smith,RN, BSN, Director of Health
RE: Approval To Amend The Contract Between the Department of Health and Human Services
Primary Health Care Program and the City of Port Arthur NO CASH MATCH
Nature of the Request: This is a request to amend the contract ID # 2016-048585-002 with
Texas Department of Health and Human Services Commission to increase the total amount of
the contract to $326,900, with $62,300 being allocated toward the contract period of September
1, 2019 through August 31, 2020. This Primary Health Care contract provides preventive health
services, including immunizations, diagnosis and treatment of acute illnesses, health education,
and diagnostic tests including lab and x-rays for eligible participants at or below 150% of the
current federal poverty guidelines.
Analysis, Considerations: The contract period starts 09/01/2019 and ends 08/31/2020 and
provides for salaries and fringe benefits for one full-time eligibility/billing clerk, office supplies
and travel expenses.
Recommendations: It is recommended that the City Council approve P.R. No. 20975 for the FY
2019-2020 contract between the Department of Health and Human 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 $326,900. The breakdown for this grant includes,
FY 2016 receiving $70,000, FY 2017 receiving $70,000, FY 2018 receiving $62,300, FY 2019
receiving $62,300 and the proposal for FY 2020 is $62,300. This is to cover the cost to operate
the Primary Health Care clinic.
"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. 20975
07/23/2019 js
RESOLUTION NO.
A RESOLUTION APPROVING THE AMENDMENT OF THE FY 2016
CONTRACT BETWEEN THE CITY OF PORT ARTHUR AND THE
DEPARTMENT OF HEALTH AND HUMAN SERVICES PRIMARY
HEALTH CARE PROGRAM, INCREASING THE AMOUNT NOT TO
EXCEED TO $326,900, OF WHICH $62,300 IS ALLOCATED TOWARD
THE CONTRACT PERIOD SEPTEMBER 1, 2019 THROUGH AUGUST
31,2020. NO CASH MATCH REQUIRED.
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, the FY 2016 Primary Health Care original contract was approved by
council on September 15, 2015, Resolution No. 15-334 for funding for FY 2016; and,
WHEREAS, this contract was amended and approved by council on June 20, 2017 per
Resolution No. 17-160 for the contract period September 1, 2017 to August 31, 2019; and
WHEREAS, this amendment is needed to the original FY 2016 contract increasing the
total contract to an amount not to exceed $326,900, of which $62,300 is being allocated toward
the contract period of September 1,2019 through August 31, 2020.
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.
P.R.No. 20975
07/23/2019-j s
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 Health and Human
Services Commission.
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 Health and Human Services Commission 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 July, 2019
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:
"Thurman Bartie. Mayor
ATTEST:
Sherri Bellard, City Secretary
P.R. No. 20975
07/23/2019-j s
APPROVED AS TO FORM:
04 6C412(.1
Val f• Cit ttorney
APPROVED FOR ADMINISTRATION:
altak jegebk
Rebecca Underhill, Interim City Manager Ju Smith, RN, BSN, Director of Health
APPROVED AS TO AVAILABILITY OF FUNDS:
Kandy Daniel, Inte Director of Finance
EXHIBIT "A"
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
HEALTH AND HUMAN SERVICES COMMISSION
CONTRACT No.2016-048585-002
AMENDMENT No.4
UNDER THE
PRIMARY HEALTH CARE GRANT PROGRAM
The HEALTH AND HUMAN SERVICES COMMISSION ("System Agency") and CITY OF PORT
ARTHUR ("Contractor"), who are collectively referred to herein as the "Parties" to that certain
Primary Health Care Contract effective September 1, 2015 and denominated HHSC Contract No.
2016-048585-002 ("Contract"),now want to amend the Contract.
WHEREAS,the Parties want to,amongst other things,exercise the final year of renewal options
in the Contract; add funds for Fiscal Year (FY) 2020 as further specified herein; revise the
Statement of Work; and add the FY 2020 renewal forms to the Contract; and
WHEREAS,the revisions will result in an addition of($62300.00)in state funds to be allocated
as further specified herein.
NOW,THEREFORE, the Parties hereby amend and modify the Contract as follows:
1. Section III of the Signature Document (Duration) is hereby amended by adding the
following:
The Contract is renewed for an additional one-year term (the "Renewal Term"). The
Renewal Term begins on September 1, 2019 and ends on August 31, 2020, unless
terminated in accordance with the terms and conditions of the Contract.
2. Section IV of the Signature Document (Budget) is hereby deleted in its entirety and
replaced with the following:
The total amount of this Contract will not exceed($326,900.00)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) $ 62,300.00
FY 2019 (September 1,2018 through August 31, 2019) $ 62,300.00
FY 2020(September 1,2019 through August 31, 2020) $ 62,300.00
All expenditures under the Contract will be in accordance with ATTACHMENT D,FY2020
BUDGET DOCUMENTS. All payments shall be made on a cost reimbursement basis.
v.1.3
4.30.19 1
DocuSign Envelope ID C09140A3-76B4-4220-875B-D5CAEOAE2B82
3. Section V of the Signature Document(Notice to Proceed) is hereby deleted in its entirety
and replaced with the following:
V. Notice to Proceed
Funding for this Contract is dependent on State Appropriations.No FY 2020 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.
4. Section VI of the Signature Document (Reporting Requirements) is hereby deleted in
its entirety and replaced with the following:
VI. Reporting Requirements
Grantee shall submit monthly, quarterly, and annual programmatic reports and/or
financial vouchers/reports as required in Attachment A-1 -Revised 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.
5. Section VII of the Signature Document(Contract Representatives)is hereby deleted in
its entirety and replaced with the following:
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: Marissa Acosta,Certified Texas Contract Manager
Grantee
City of Port Arthur
2600 Cedar Ave.
Port Arthur,TX 78040
Attention: Rosario Cabello,Interim Co-City Manager
6. Indirect Cost Rate: The Grantee's acknowledged or approved Indirect Cost Rate(ICR)
is contained within ATTACHMENT D,FY2020 BUDGET DOCUMENTS and either the ICR
Acknowledgement Letter, ICR Acknowledgement Letter—Ten Percent De Minimis, or
the ICR Agreement Letter is attached to this Contract and incorporated as ATTACHMENT
E,INDIRECT COST RATE LETTER.
v.1.3
4.30.19 2
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
If an Indirect Cost Rate Letter is required but it is not issued at the time of Contract
execution,the Parties agree to amend the Contract to include the Indirect Cost Rate Letter
as ATTACHMENT E and revise when the Indirect Cost Rate Letter is issued.
7. Attachment A of the Signature Document (Statement of Work) is hereby deleted in its
entirety and replaced with the following attachment: Attachment A-1 Revised Statement
of Work
8. Attachment B - Special Conditions, is hereby deleted in its entirety and replaced with the
updated Attachment B-Special Conditions Version,which is attached to this Amendment
and incorporated into the Contract as if fully set forth therein.
9. This Amendment shall be effective as of September 1, 2019.
10. Except as amended and modified by this Amendment, all terms and conditions of the
Contract, as amended, shall remain in full force and effect.
11. Any further revisions to the Contract shall be by written agreement of the Parties.
SIGNATURE PAGE FOLLOWS
v.1.3
4.30.19 3
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
SIGNATURE PAGE FOR AMENDMENT No.4
HEALTH AND HUMAN SERVICES COMMISSION
CONTRACT No.2016-048585-002
HEALTH AND HUMAN SERVICES CITY OF PORT ARTHUR
COMMISSION
Lindsay Rodgers ViaD a F. _4, e}}a Re is - V n cue r h
.. 11
Associate Commissioner Title: Interim Co-City Manager
Date of Execution: Date of Execution:
THE FOLLOWING ATTACHMENTS ARE ATTACHED AND INCORPORATED AS PART OF THE
CONTRACT:
ATTACHMENT A-1—REVISED STATEMENT OF WORK
ATTACHENT B—SPECIAL CONDITIONS
ATTACHMENT C-FY 2020 RENEWAL FORMS
ATTACHMENT D-FY 2020 BUDGET DOCUMENTS •
ATTACHMENT E-INDIRECT COST RATE LETTER,IF APPLICABLE
v.1.3
4.30.19 4
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
ATTACHMENT A-1
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 C --Grantee's FY 2020 Renewal Forms;
2. HHSC Primary Health Care Program Policy Manual located at
https://hhs.texas.gov/doing-business-hhs/provider-portals/health-services-
providers/primary-health-care-services-program, as amended; and
3. Department of State Health Services Standards for Public Health Clinic
Services, 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.
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
ATTACHMENT A-1
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.
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.
Financial Status Quarterly
Report(FSR)
Q 1: September 1 —Nov 30 Q 1: 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 HDS.ADS@hhsc.state.tx.us
and PHCReports@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,
ethnicity, number of unduplicated clients, etc.) as detailed in PHC annual report
Form 325. Grantee shall email the report to the PHC mailbox
PHCReports@hhsc.state.tx.us.
DocuSign Envelope ID: C09140A3-7684-4220-875B-D5CAEOAE2B82
ATTACHMENT A-1
STATEMENT OF WORK
3. Financial Status Report (FSR): Grantee shall submit quarterly FSRs to the Health
and Developmental Services, Office of Primary and Specialty Health, 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 2020 PHC
client co-pay policy and fee schedules to the PHC mailbox
(PHCReports@,hhsc.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
monies donated to the program by individuals and private groups, such as churches or
other organizations.
L. Contractor shall 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; to be held in Austin,
DocuSign Envelope ID:C09140A3-7684-4220-8758-D5CAEOAE2B82
ATTACHMENT A-1
STATEMENT OF WORK
Dallas/Fort Worth, Houston or San Antonio in the fall, spring or summer of fiscal year
2020.
M. Allow System Agency to conduct on-site quality assurance reviews as deemed
necessary by System Agency. Unsatisfactory review fmdings may result in
implementation of contract actions up to and including termination of the Contract.
N. 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).
O. Initiate the purchase of all equipment approved in writing by System Agency by the
last business day of May in each Contract year.
P. 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:
• For FY 2020, Grantee shall provide services to a minimum of 356 unduplicated
clients at an average cost per client of$175.00 for 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.
111. BILLING INSTRUCTIONS
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 final
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 email address provide on the form.
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
ATTACHMENT A-1
STATEMENT OF WORK
C. Grantee shall submit Form 4116 each month for actual program expenditures,even if there
are zero expenditures or if the contract budget limit has been reached. Contractor may be
asked to submit additional documentation to verify expenditures.
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.
DocuSign Envelope ID:C09140A3-76B4-4220-8758-D5CAEOAE2B82
Attachment B - Special Conditions
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
i Crow igloo I I.1 TE )(As
. ,„
I ita v E
\' 4 4,‘ : Health and Human Services
Se il
Health and Human Services Commission
Special Conditions
Version 1.2
9.1.17
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
Contents
Article I. Special Definitions 1
Article II. General Provisions 2
Section 2.01 Other System Agencies Participation in the Contract 2
Section 2.02 Most Favored Customer 2
Section 2.03 Cooperation with HHSC Vendors 3
Section 2.04 Renegotiation and Reprocurement Rights 3
Article III. Contractors Personnel and Subcontractors 3
Section 3.01 Qualifications 3
Section 3.02 Conduct and Removal
Article IV. Performance 4
Section 4.01 Measurement 4
Article V. Amendments and Modifications 4
Section 5.01 Formal Procedure 4
Section 5.02 Minor Administrative Changes 4
Article VI. Payment 4
Section 6.01 Enhanced Payment Procedures 4
Article VII. Confidentiality 5
Section 7.01 Consultant Disclosure 5
Section 7.02 Confidential System Information 5
Article VIII. Disputes and Remedies 6
Section 8.01 Agreement of the Parties 6
Section 8.02 Operational Remedies 6
Section 8.03 Equitable Remedies 7
Section 8.04 Continuing Duty to Perform 7
Article IX. Damages 7
Section 9.01 Availability and Assessment 7
Section 9.02 Specific Items of Liability 7
Article X. Turnover 8
Section 10.01 Turnover Plan 8
Section 10.02 Turnover Assistance 8
Article XI. Additional License and Ownership Provisions 8
Section 11.01 HHSC Additional Rights 8
Section 11.02 Third Party Software 8
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
Section 11.03 Software and Ownership Rights 9
Article XII. Uniform ICT Accessibility Clause 9
Section 12.01 Applicability 9
Section 12.02 Definitions 9
Section 12.03 Accessibility Requirements 10
Section 12.04 Evaluation, Testing and Monitoring 10
Section 12.05 Representations and Warranties 11
Section 12.06 Remedies 11
Article XIII. Miscellaneous Provisions 11
Section 13.01 Conflicts of Interest 11
Section 13.02 Flow Down Provisions 12
Section 13.03 Manufacturer's Warranties 12
Article XIV. DSHS Legacy Provisions 12
Section 14.01 Notice of Criminal Activity and Disciplinary Actions 12
Section 14.02 Notice of IRS or TWC Insolvency 13
Section 14.03 Education to Persons in Residential Facilities 13
Section 14.04 Disaster Services 13
Section 14.05 Consent by Non-Parent or Other State Law to Medical Care of a Minor 14
Section 14.06 Telemedicine/Telepsychiatry Medical Services 14
Section 14.07 Services and Information for Persons with Limited English Proficiency 14
Section 14.08 Third Party Payors 14
Section 14.09 HIV/AIDS Model Workplace Guidelines 15
Section 14.10 Medical Records Retention 15
Section 14.11 Notice of a License Action 15
Section 14.12 Interim Extension Amendment 15
Section 14.13 Child Abuse Reporting Requirement 16
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
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 Uniform Terms and Conditions—Vendor-Version 2.14
Article I. SPECIAL DEFINITIONS
"Conflict of Interest"means a set of facts or circumstances,a relationship,or other situation under which
Contractor, 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 Contractor's, or
Subcontractor's ability to render impartial or objective assistance or advice to the HHSC; or(2) provides
the Contractor or Subcontractor an unfair competitive advantage in future HHSC procurements.
"Contractor Agents"means Contractor's representatives,employees,officers, Subcontractors,as well as
their employees,contractors, officers,and agents.
"Custom Software"means Software developed as a Deliverable or in connection with the Agreement.
"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 Contractor's acts or omissions that: (1) violate a provision of the
Contract; (2) fail to ensure adequate performance of the Work; (3)represent a failure of Contractor to be
responsive to a request of HHSC relating to the Work 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 5.02 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 Contractor; or
that Contractor may create,receive,maintain,use,disclose or have access to on behalf of HHSC or through
performance of the Work,which is not designated as Confidential Information in aData 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 Contractor to perform
the Work under the Contract.
"Third Party Software" refers to software programs or plug-ins developed by companies or individuals
other than Contractor which are used in performance of the Work. It does not include items which are
ancillary to the performance of the Work, such as internal systems of Contractor which were deployed by
Contractor prior to the Contract and not procured to perform the Work.
Page 1 of 16
V 1.2
9.1.17
DocuSign Envelope ID.C09140A3-76B4-4220-875B-D5CAEOAE2B82
"Turnover" means the effort necessary to enable HHSC, or its designee, to effectively close out the
Contract and move the Work to another vendor or to perform the Work by itself.
"Turnover Plan" means the written plan developed by Contractor, approved by HHSC, and to be
employed when the Work described in the Contract transfers to HHSC,or its designee,from the Contractor.
"UTC"means HHSC's Uniform Terms and Conditions-Vendor—Version 2.15
Article II. GENERAL PROVISIONS
2.01 Other System Agencies Participation in the Contract
In addition to providing the Work specified for HHSC,Contractor agrees to allow other System Agencies
the option to participate in the Contract under the same terms and conditions. Each System Agency that
elects to obtain Work under this section will issue a purchase or Work order to Contractor,referring to,and
incorporating by reference,the terms and conditions specified in the Contract.
System Agencies have no authority to modify the terms of the Contract. However, additional System
Agency terms and conditions that do not conflict with the Contract, and are acceptable to the Contractor,
may be added in a purchase or Work order and given effect. No additional term or condition added in a
purchase or Work order issued by a System Agency can conflict with or diminish a term or condition of the
Contract. In the event of a conflict between a System Agency's purchase or Work order and the Contract,
the Contract terms control.
2.02 Most Favored Customer
Contractor agrees that if during the term of the Contract, Contractor enters into any agreement with any
other governmental customer, or any non-affiliated commercial customer by which it agrees to provide
equivalent services at lower prices, or additional services at comparable prices, Contractor will notify
HHSC within(10)business days from the date Contractor executes any such agreement. Contractor agrees,
at HHSC's option,to amend the Contract to accord equivalent advantage to HHSC.
Page 2 of 16
V 1.2
9.1.17
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
2.03 Cooperation with HHSC Vendors
At HHSC's request, Contractor will allow parties interested in responding to other HHSC solicitations to
have reasonable access during normal business hours to the Work, software, systems documentation, and
site visits to the Contractor's facilities. Contractor may elect to have such parties inspecting the Work,
facilities, software or systems documentation to agree to use the information so obtained only in the State
of Texas and only for the purpose of responding to the relevant HHSC solicitation.
2.04 Renegotiation and Reprocurement Rights
Notwithstanding anything in the Contract to the contrary, HHSC may at any time during the term of the
Contract exercise the option to notify Contractor that HHSC has elected to renegotiate certain terms of the
Contract. Upon Contractor's receipt of any notice under this section,Contractor and HHSC will undertake
good faith negotiations of the subject terms of the Contract.
HHSC may at any time issue solicitation instruments to other potential contractors for performance of any
portion of the Work covered by the Contract, including services similar or comparable to the Work,
performed by Contractor under the Contract. If HHSC elects to procure the Work, or any portion thereof,
from another vendor in accordance with this section,HHSC will have the termination rights set forth in the
UTC.
Article III. CONTRACTORS PERSONNEL AND SUBCONTRACTORS
3.01 Qualifications
Contractor 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.
Contractor 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, Contractor remains obligated to perform all duties and responsibilities under the
Contract without degradation and in strict accordance with the terms of the Contract.
3.02 Conduct and Removal
While performing the Work under the Contract, Contractor 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 Contractor Agent is not conducting himself or herself in
accordance with the terms of the Contract, HHSC may provide Contractor with notice and documentation
regarding its concerns. Upon receipt of such notice,Contractor must promptly investigate the matter and,
at HHSC's election, take appropriate action that may include removing the Contractor Agent from
performing any Work under the Contract and replacing the Contractor Agent with a similarly qualified
individual acceptable to HHSC as soon as reasonably practicable or as otherwise agreed to by HHSC.
Page 3 of 16
V 1.2
9.1.17
DocuSign Envelope ID:009140A3-76B4-4220-875B-D5CAEOAE2B82
Article IV. PERFORMANCE
4.01 Measurement
Satisfactory performance of the Contract,unless otherwise specified in the Contract,will be measured by:
(a) Compliance with Contract requirements, including all representations and warranties;
(b) Compliance with the Work requested in the Solicitation and Work proposed by Contractor in its
response to the Solicitation and approved by HHSC;
(c) Delivery of Work in accordance with the service levels proposed by Contractor in the Solicitation
Response as accepted by HHSC;
(d) Results of audits, inspections,or quality checks performed by the HHSC or its designee;
(e) Timeliness,completeness,and accuracy of Work;and
(f) Achievement of specific performance measures and incentives as applicable.
Article V. AMENDMENTS AND MODIFICATIONS
5.01 Formal Procedure
No different or additional Work or contractual obligations will be authorized or performed unless
contemplated within the Scope of Work and memorialized in an amendment or modification of the Contract
that is executed in compliance with this Article. No waiver of any term, covenant, or condition of the
Contract will be valid unless executed in compliance with this Article. Contractor will not be entitled to
payment for Work that is not authorized by a properly executed Contract amendment or modification, or
through the express written authorization of HHSC.
Any changes to the Contract that results in a change to either the term, fees, or significantly impacting the
obligations of the parties to the Contract must be effectuated by a formal Amendment to the Contract. Such
Amendment must be signed by the appropriate and duly authorized representative of each party in order to
have any effect.
5.02 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 Work 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 Section 5.01 of these Special
Conditions. Upon approval of a Minor Administrative Change,HHSC and Contractor will maintain written
notice that the change has been accepted in their Contract files.
Article VI. PAYMENT
6.01 Enhanced Payment Procedures
Page 4 of 16
V 1.2
9.1.17
DocuSign Envelope ID:009140A3-76B4-4220-875B-D5CAEOAE2B82
HHSC will be relieved of its obligation to make any payments to Contractor until such time as any and all
set-off amounts have been credited to HHSC. If HHSC disputes payment of all or any portion of an invoice
from Contractor,HHSC will notify the Contractor of the dispute and both Parties will attempt in good faith
to resolve the dispute in accordance with these Special Conditions. HHSC will not be required to pay any
disputed portion of a Contractor invoice unless, and until, the dispute is resolved. Notwithstanding any
such dispute, Contractor will continue to perform the Work in compliance with the terms of the Contract
pending resolution of such dispute so long as all undisputed amounts continue to be paid to Contractor.
Article VII. CONFIDENTIALITY
7.01 Consultant Disclosure
Contractor agrees that any consultant reports received by HHSC in connection with the Contract may be
distributed by HHSC,in its discretion,to any other state agency and the Texas legislature. Any distribution
may include posting on HHSC's website or the website of a standing committee of the Texas Legislature.
7.02 Confidential System Information
HHSC prohibits the unauthorized disclosure of Other Confidential Information. Contractor and all
Contractor Agents will not disclose or use any Other Confidential Information in any manner except as is
necessary for the Work or the proper discharge of obligations and securing of rights under the Contract.
Contractor will have a system in effect to protect Other Confidential Information. Any disclosure or transfer
of Other Confidential Information by Contractor, including information requested to do so by HHSC,will
be in accordance with the Contract. If Contractor receives a request for Other Confidential Information,
Contractor 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.
Contractor 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 Contractor.
Contractor 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 Contractor all damages and liabilities caused by or arising from
Contractor or Contractor Agents' failure to protect HHSC's Confidential Information as required by this
section.
IN COORDINATION WITH THE INDEMNITY PROVISIONS CONTAINED IN
THE UTC, Contractor 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 Contractor OR Contractor AGENTS FAILURE
TO PROTECT OTHER CONFIDENTIAL INFORMATION. Contractor WILL
FULFILL THIS PROVISION WITH COUNSEL APPROVED BY HHSC.
Page 5 of 16
V 1.2
9.1.17
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
Article VIII. DISPUTES AND REMEDIES
8.01 Agreement of the Parties
The Parties agree that the interests of fairness,efficiency,and good business practices are best served when
the Parties employ all reasonable and informal means to resolve any dispute under the Contract before
resorting to formal dispute resolution processes otherwise provided in the Contract. The Parties will use
all reasonable and informal means of resolving disputes prior to invoking a remedy provided elsewhere in
the Contract, unless HHSC immediately terminates the Contract in accordance with the terms and
conditions of the Contract.
Any dispute,that in the judgment of any Party to the Agreement,may materially affect the performance of
any Party will be reduced to writing and delivered to the other Party within 10 business days after the
dispute arises. The Parties must then negotiate in good faith and use every reasonable effort to resolve the
dispute at the managerial or executive levels prior to initiating formal proceedings pursuant to the UTC and
Texas Government Code §2260, unless a Party has reasonably determined that a negotiated resolution is
not possible and has so notified the other Party. The resolution of any dispute disposed of by agreement
between the Parties will be reduced to writing and delivered to all Parties within 10 business days of such
resolution.
8.02 Operational Remedies
The remedies described in this section may be used or pursued by HHSC in the context of the routine
operation of the Contract and are directed to Contractor's timely and responsive performance of the Work
as well as the creation of a flexible and responsive relationship between the Parties. Contractor agrees that
HHSC may pursue operational remedies for Items of Noncompliance with the Contract. At any time, and
at its sole discretion, HHSC may impose or pursue one or more said remedies for each Item of
Noncompliance. HHSC will determine operational remedies on a case-by-case basis which include, but
are not,limited to:
(a) Requesting a detailed Corrective Action Plan, subject to HHSC approval,to correct and resolve a
deficiency or breach of the Contract;
(b) Require additional or different corrective action(s)of HHSC's choice;
(c) Suspension of all or part of the Contract or Work;
(d) Prohibit Contractor from incurring additional obligations under the Contract;
(e) Issue Notice to stop Work Orders;
(f) Assessment of liquidated damages as provided in the Contract;
(g) Accelerated or additional monitoring;
(h) Withholding of payments; and
(i) Additional and more detailed programmatic and financial reporting.
HHSC's pursuit or non-pursuit of an operational remedy does not constitute a waiver of any other remedy
that HHSC may have at law or equity; excuse Contractor's prior substandard performance, relieve
Contractor of its duty to comply with performance standards,or prohibit HHSC from assessing additional
operational remedies or pursuing other appropriate remedies for continued substandard performance.
HHSC will provide notice to Contractor of the imposition of an operational remedy in accordance with this
section, with the exception of accelerated monitoring, which may be unannounced. HHSC may require
Contractor to file a written response as part of the operational remedy approach.
Page 6 of 16
V 1.2
9.1.17
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
8.03 Equitable Remedies
Contractor acknowledges that if,Contractor breaches,attempts,or threatens to breach,any obligation under
the Contract,the State will be irreparably harmed. In such a circumstance,the State may proceed directly
to court notwithstanding any other provision of the Contract. If a court of competent jurisdiction finds that
Contractor breached, attempted, or threatened to breach any such obligations, Contractor will not oppose
the entry of an order compelling performance by Contractor and restraining it from any further breaches,
attempts,or threats of breach without a further finding of irreparable injury or other conditions to injunctive
relief.
8.04 Continuing Duty to Perform
Neither the occurrence of an event constituting an alleged breach of contract, the pending status of any
claim for breach of contract,nor the application of an operational remedy, is grounds for the suspension of
performance, in whole or in part, by Contractor of the Work or any duty or obligation with respect to the
Contract.
Article IX. DAMAGES
9.01 Availability and Assessment
HHSC will be entitled to actual, direct, indirect, incidental, special, and consequential damages resulting
from Contractor's failure to comply with any of the terms of the Contract. In some cases,the actual damage
to HHSC as a result of Contractor's failure to meet the responsibilities or performance standards of the
Contract are difficult or impossible to determine with precise accuracy. Therefore, if provided in the
Contract,liquidated damages may be assessed against Contractor for failure to meet any aspect of the Work
or responsibilities of the Contractor. HHSC may elect to collect liquidated damages:
(a) Through direct assessment and demand for payment to Contractor;or
(b) By deducting the amounts assessed as liquidated damages against payments owed to Contractor for
Work performed. In its sole discretion,HHSC may deduct amounts assessed as liquidated damages
as a single lump sum payment or as multiple payments until the full amount payable by the
Contractor is received by the HHSC.
9.02 Specific Items of Liability
Contractor bears all risk of loss or damage due to defects in the Work, unfitness or obsolescence of the
Work,or the negligence or intentional misconduct of Contractor or Contractor Agents. Contractor will ship
all equipment and Software purchased and Third Party Software licensed under the Contract, freight
prepaid,FOB HHSC's destination. The method of shipment will be consistent with the nature of the items
shipped and applicable hazards of transportation to such items. Regardless of FOB point,Contractor bears
all risks of loss, damage, or destruction of the Work, in whole or in part, under the Contract that occurs
prior to acceptance by HHSC. After acceptance by HHSC, the risk of loss or damage will be borne by
HHSC; however, Contractor remains liable for loss or damage attributable to Contractor's fault or
negligence.
Contractor will protect HHSC's real and personal property from damage arising from Contractor or
Contractor Agents performance of the Contract,and Contractor will be responsible for any loss,destruction,
or damage to HHSC's property that results from or is caused by Contractor or Contractor Agents' negligent
Page 7 of 16
V 1.2
9.1.17
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
or wrongful acts or omissions. Upon the loss of, destruction of, or damage to any property of HHSC,
Contractor will notify HHSC thereof and, subject to direction from HHSC or its designee, will take all
reasonable steps to protect that property from further damage. Contractor agrees, and will require
Contractor Agents,to observe safety measures and proper operating procedures at HHSC sites at all times.
Contractor will immediately report to the HHSC any special defect or an unsafe condition it encounters or
otherwise learns about.
IN COORDINATION WITH THE INDEMNITY PROVISIONS CONTAINED IN
THE UTC, Contractor WILL BE SOLELY RESPONSIBLE FOR ALL COSTS
INCURRED THAT ARE ASSOCIATED WITH INDEMNIFYING THE STATE OF
TEXAS OR HHSC WITH RESPECT TO INTELLECTUAL, REAL AND
PERSONAL PROPERTY. ADDITIONALLY,HHSC RESERVES THE RIGHT TO
APPROVE COUNSEL SELECTED BY Contractor TO DEFEND HHSC OR THE
STATE OF TEXAS AS REQUIRED UNDER THIS SECTION.
Article X. TURNOVER
10.01 Turnover Plan
HHSC may require Contractor to develop a Turnover Plan at any time during the term of the Contract in
HHSC's sole discretion. Contractor must submit the Turnover Nan to HHSC for review and approval. The
Turnover Plan must describes Contractor's policies and procedures that will ensure:
(a) The least disruption in the delivery the Work during Turnover to HHSC or its designee;and
(b) Full cooperation with HHSC or its designee in transferring the Work and the obligations of the
Contract.
10.02 Turnover Assistance
Contractor will provide any assistance and actions reasonably necessary to enable HHSC or its designee to
effectively close out the Contract and transfer the Work and the obligations of the Contract to another
vendor or to perform the Work by itself. Contractor agrees that this obligation survives the termination,
regardless of whether for cause or convenience,or the expiration of the Contract and remains in effect until
completed to the satisfaction of HHSC.
Article XI. ADDITIONAL LICENSE AND OWNERSHIP PROVISIONS
11.01 HHSC Additional Rights
HHSC will have ownership and unlimited rights to use, disclose, duplicate, or publish all information and
data developed, derived, documented, or furnished by Contractor under or resulting from the Contract.
Such data will include all results,technical information,and materials developed for or obtained by HHSC
from Contractor in the performance of the Work. If applicable, Contractor will reproduce and include
HHSC's copyright,proprietary notice,or any product identifications provided by Contractor.
11.02 Third Party Software
Page 8of16
V 1.2
9.1.17
DocuSign Envelope ID:C09140A3-76B4-4220-8758-D5CAEOAE2B82
Contractor grants HHSC a non-exclusive,perpetual, license for HHSC to use Third Party Software and its
associated documentation for its internal business purposes. HHSC will be entitled to use Third Party
Software on the equipment or any replacement equipment used by HHSC,and with any replacement Third
Party Software chosen by HHSC,without additional expense.
Terms in any licenses for Third Party Software will be consistent with the requirements of this section.
Prior to utilizing any Third Party Software product not identified in the Solicitation Response, Contractor
will provide HHSC copies of the license agreement from the licensor of the Third Party Software to allow
HHSC to, in its discretion, object to the license agreement that must, at a minimum, provide HHSC with
necessary rights consistent with the short and long-term goals of the Contract. Contractor will assign to
HHSC all licenses for the Third Party Software as necessary to carry out the intent of this section.
Contractor will,during the Contract,maintain any and all Third Party Software at their most current version
or no more than one version back from the most current version. However, Contractor will not maintain
any Third Party Software versions,including one version back, if notified by HHSC that any such version
would prevent HHSC from using any functions, in whole or in part, of HHSC systems or would cause
deficiencies in HHSC systems.
11.03 Software and Ownership Rights
In accordance with 45 C.F.R. Part 95.617, all appropriate federal agencies will have a royalty-free,
nonexclusive, and irrevocable license to reproduce, publish, translate, or otherwise use, and to authorize
others to use for government purposes all Work, materials, Custom Software and modifications thereof,
source code, associated documentation designed, developed, or installed with Federal Financial
Participation under the Contract, including but not limited to those materials covered by copyright.
Article XII.UNIFORM ICT ACCESSIBILITY CLAUSE
12.01 Applicability
This Section applies to the procurement or development of Information and Communication Technology
(ICT) for HHSC, or any changes to HHSC's ICT. This Section also applies if the Contract requires
Contractor to perform a service or supply a goods that include ICT that:(i)HHSC employees are required
or permitted to access; or(ii) members of the publis are required or permitted to access. This Section
does not apply to incidental uses of ICT in the performance of a contract,unless the parties agree that the
ICT will become property of the state or will be used by HHSC's Client/Recipeint after completion of
the Contract.
Nothing in this section is intended to prescribe the use of particular designs or technologies or to prevent
the use of alternative technologies,provided they result in substantially equivalent or greater access to and
use of a product/service.
12.02 Definitions
The legacy term `Electronic and Information Resources" (EIR) and the term "Information and
Communication Technology"(ICT) are considered equivalent in meaning for the purpose of applicability
of HHSC Uniform Terms and Conditions, policies, accessibility checklists, style guides, contract
specifications, and other contract management documents. To the extent that any other of the following
definitions conflict with definitions elsewhere in this Contract, the following definitions are applicable to
this Section only.
Page 9 of 16
V 1.2
9.1.17
DocuSign Envelope ID C09140A3-76B4-4220-875B-D5CAEOAE2B82
1. "Accessibility Standards" refers to the Information and Communication Technology
Accessibility Standards and the Web Accessibility Standards/Specifications under the Web
Content Accessibility Guidelines version 2.0 Level AA,(WCAG 2.0).
2. "Information and Communication Technology (ICT)" is any information technology,
equipment, or interconnected system or subsystem of equipment for which the principal
function is the creation, conversion, duplication, automatic acquisition, storage, analysis,
evaluation, manipulation, management, movement, control, display, switching, interchange,
transmission, reception, or broadcast of data or information. Examples of ICT are electronic
content, telecommunications products, computers and ancillary equipment, software,
information kiosks and transaction machines, videos, IT services, and multifunction office
machines which copy, scan,and fax documents.
3. "Information and Communication Technology Accessibility Standards" refers to the
accessibility standards for information and communication technology contained in the Web
Content Accessibility Guidelines version 2.0 Level AA.
4. "Web Accessibility Standards/Specifications" refers to the web standards contained in
WCAG 2.0 Level AA.
5. "Products"means information resources technologies that are,or are related to, ICT.
6. "Service"means the act of delivering information or performing a task for employees,clients,
or members of the public through a method of access or delivery that uses ICT.
12.03 Accessibility Requirements
Under Texas Government Code Chapter 2054, Subchapter M, and implementing rules of the Texas
Department of Information Resources, HHSC must procure Products or Services that comply with the
Accessibility Standards when such Products or Services are available in the commercial marketplace or
when such Products or Services are developed in response to a procurement solicitation. Accordingly,
Contractor must provide ICT and associated Product and/or Service documentation and technical support
that comply with the Accessibility Standards.
12.04 Evaluation,Testing and Monitoring
1. HHSC may review,test, evaluate and monitor Contractor's Products, Services and associated
documentation and technical support for compliance with the Accessibility Standards. Review,
testing, evaluation and monitoring may be conducted before and after the award of a contract.
Testing and monitoring may include user acceptance testing.
1. Neither(1)the review,testing(including acceptance testing),evaluation or monitoring of any
Product or Service,nor(2)the absence of such review, testing, evaluation or monitoring,will
result in a waiver of the State's right to contest the Contractor's assertion of compliance with
the Accessibility Standards.
Page 10 of 16
V 1.2
9.1.17
DocuSign Envelope ID C09140A3-76B4-4220-875B-D5CAEOAE2B82
2. Contractor agrees to cooperate fully and provide HHSC and its representatives timely access
to Products, Services,documentation,and other items and information needed to conduct such
review,evaluation,testing and monitoring.
12.05 Representations and Warranties
1. Contractor represents and warrants that:(i)as of the effective date of the contract,the Products,
Services and associated documentation and technical support comply with the Accessibility
Standards as they exist at the time of entering the contract, unless and to the extent the Parties
otherwise expressly agree in writing; and(ii)if the Products will be in the custody of the state
or an HHS agency's client or recipient after the contract expiration or termination,the Products
will continue to comply with such Accessibility Standards after the expiration or termination
of the contract term, unless HHSC and/or Client/Recipient,as applicable uses the Products in
a manner that renders it noncompliant.
2. In the event Contractor should have known,becomes aware,or is notified that the Product and
associated documentation and technical support do not comply with the Accessibility
Standards,Contractor represents and warrants that it will,in a timely manner and at no cost to
HI-ISC, perform all necessary steps to satisfy the Accessibility Standards, including but not
limited to remediation, repair, replacement, and upgrading of the Product, or providing a
suitable substitute.
3. Contractor acknowledges and agrees that these representations and warranties are essential
inducements on which HHSC relies in awarding this contract.
4. Contractor's representations and warranties under this subsection will survive the termination
or expiration of the contract and will remain in full force and effect throughout the useful life
of the Product.
12.06 Remedies
1. Pursuant to Texas Government Code Sec. 2054.465, neither Contractor nor any other person
has cause of action against HHSC for a claim of a failure to comply with Texas Government
Code Chapter 2054, Subchapter M,and rules of the Department of Information Resources.
2. In the event of a breach of Contractor's representations and warranties,Contractor will be liable
for direct and consequential damages and any other remedies to which HHSC may be entitled.
This remedy is cumulative of any and all other remedies to which HHSC may be entitled under
this contract and other applicable law.
Article XIII. MISCELLANEOUS PROVISIONS
13.01 Conflicts of Interest
Page 11 of 16
V 1.2
9.1.17
DocuSign Envelope ID C09140A3-76B4-4220-875B-D5CAEOAE2B82
Contractor 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 Contractor
or Contractor 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. Contractor will,and require Contractor
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. Contractor and Contractor 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.
Contractor agrees that, if after Contractor's execution of the Contract, Contractor discovers or is made
aware of a Conflict of Interest, Contractor will immediately and fully disclose such interest in writing to
HHSC. In addition, Contractor will promptly and fully disclose any relationship that might be perceived
or represented as a conflict after its discovery by Contractor or by HI-ISC as a potential conflict. HHSC
reserves the right to make a final determination regarding the existence of Conflicts of Interest, and
Contractor agrees to abide by HHSC's decision.
If HHSC determines that Contractor 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.
13.02 Flow Down Provisions
Contractor 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.
13.03 Manufacturer's Warranties
Contractor assigns to HHSC all of the manufacturers' warranties and indemnities relating to the Work,
including without limitation, Third Party Software, to the extent Contractor is permitted by the
manufacturers to make such assignments to HHSC.
Article XIV. DSHS LEGACY PROVISIONS
14.01 Notice of Criminal Activity and Disciplinary Actions
(a) Contractor shall immediately report in writing to their contract manager when Contractor has
knowledge or any reason to believe that they or any person with ownership or controlling interest
Page 12 of 16
V 1.2
9.1.17
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
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) Contractor 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.
14.02 Notice of IRS or TWC Insolvency
Contractor 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.
14.03 Education to Persons in Residential Facilities
Contractor shall ensure that all persons, who are housed in System Agency licensed or funded residential
facilities and are 22 years of age or younger, have access to educational services as required by Texas
Education Code §29.012.
Contractor shall notify the local education agency or local early intervention program as prescribed by this
Section not later than the third calendar day after the date a person who is 22 years of age or younger is
placed in Contractor's residential facility
14.04 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, Contractor 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.
Page 13 of 16
V 1.2
9.1.17
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
14.05 Consent by Non-Parent or Other State Law to Medical Care of a Minor
Unless a federal law applies, before a Contractor 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.
14.06 Telemedicine/Telepsychiatry Medical Services
If Contractor or its subcontractor uses telemedicine/telepsychiatry, these services shall be in accordance
with the Contractor's written procedures. Contractor must use a protocol approved by Contractor's medical
director and equipment that complies with the System Agency equipment standards, if applicable.
Contractor's procedures for providing telemedicine service must include the following requirements:
(a) Clinical oversight by Contractor's medical director or designated physician responsible for
medical leadership;
(b) Contraindication considerations for telemedicine use;
(c) Qualified staff members to ensure the safety of the individual being served by
telemedicine at the remote site;
(d) Safeguards to ensure confidentiality and privacy in accordance with state and federal laws;
(e) Use by credentialed licensed providers providing clinical care within the scope of their licenses;
(f) Demonstrated competency in the operations of the system by all staff members who are
involved in the operation of the system and provision of the services prior to initiating the
protocol;
(g) Priority in scheduling the system for clinical care of individuals;
(h) Quality oversight and monitoring of satisfaction of the individuals served;and
(i) Management of information and documentation for telemedicine services that ensures timely
access to accurate information between the two sites. Telemedicine Medical Services does not
include chemical dependency treatment services provided by electronic means under 25 Texas
Administrative Code Rule §448.911.
14.07 Services and Information for Persons with Limited English Proficiency
(a) Contractor 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) Contractor 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) Contractor 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.
14.08 Third Party Payors
Page 14 of 16
V 1.2
9.1.17
DocuSign Envelope ID C09140A3-76B4-4220-875B-D5CAEOAE2B82
Except as provided in this Contract, Contractor 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 Contractor 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.
14.09 HIV/AIDS Model Workplace Guidelines
Contractor 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
Contractors Policy No. 090.021.
Contractor 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.
14.10 Medical Records Retention
Contractor shall retain medical records in accordance with 22 TAC §165.1(b) or other applicable statutes.
rules and regulations governing medical information.
14.11 Notice of a License Action
Contractor 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.
14.12 Interim Extension Amendment
(a) Prior to or on the expiration date of this Contract, the Parties agree that this Contract can be
Page 15 of 16
V 1.2
9.1.17
DocuSign Envelope ID.C09140A3-76B4-4220-875B-D5CAEOAE2B82
extended as provided under this Section.
(b) The System Agency shall provide written notice of interim extension amendment to the
Contractor 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) Contractor 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.
14.13 Child Abuse Reporting Requirement
(a) Contractors 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 Contractor to report child abuse.
(b) Contractor 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
Contractors/Providers and train all staff on reporting requirements.
(c) Contractor 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. Contractor shall
retain reporting documentation on site and make it available for inspection by the System
Agency.
REMAINDER OF PAGE INTENTIONALLY LEFT BLANK
Page 16 of 16
V 1.2
9.1.17
DocuSign Envelope ID:C09140A3-7664-4220-875B-D5CAEOAE2B82
Attachment C - FY 2020 Renewal
Forms
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
i I V Office of Primary and Specialty Health
Y f
.t Primary Health Care Contractor Renewal for Financial Assistance
:'�; ...a: Health and Human
Services FORM A: FACE PAGE
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.
ESPONDENT INFORMATION
•)LEGAL BUSINESS NAME:City of Port Arthur
r)MAILING Address Information(include mailing address,street,city,county,state and zip code): Check If address change D
449 Austin Avenue, Port Arthur, Texas 77640
c)PAYEE Name and Mailing Address(if different from above): Check if address change ❑
Same as above
Federal Tax ID No.(9 digit),State of Texas Comptroller Vendor ID No.(14 digit)or Social Security Number(9 digit):
17460018850011
'The respondent odvsawdeddes,understands and agrees that the respondent's choke to use a social security number as the vendor identification
umber for the earruact,may result in the social security member being made public via state open records requests.
-)Medicaid Provider Number: 13335 ; 40 9 OR Date Medicaid Application Submitted&TMHP Ticket N:
)DUNS Number:137134909
LLYPE OF ENTITY(check all that appy
n City I Nonprofit Organization` Individual
County For Profit Organization* FQHC
«r Other Political Subdivision HUB Certified State Controlled Institution of Higher Learning i
State Agency tt Community-Based Organization Hospital
rml
Indian Tribe ... Minority Organization Private f
Faith Based(Nonprofit Org) Other(specify): 1�
'If incorporated,provide 10-digit charter number assigned by Secretary of State'
:)PROPOSED BUDGET AND PERIOD: $62,300 !start Date: September 1,2019d Date: August 31,2020
1COUNTIES SERVED BY PROJECT:See attached list.Include completed Form A-1 behind Form A:Face Page.
0)PHC PROJECT CONTACT PERSON
ame:Judith A. Smith, RN, BSN Phone:409-983-8832
ax:409-983-1530 Email:judith.smith@portarthurtx.gOv
11)FINANCIAL OFFICER
ane:Kandi Daniel frhone:409-983-8174
Fax:409-984-5463 mail:kandi.daniel@portarthurtx.gov
he facts affirmed by me in this proposal are truthful and I warrant the respondent is In compliance with the assurances and certifications contained
n HHSC Assurances and Certifications.I understand the truthfulness of the facts affirmed herein and the continuing compliance with these
equirements are conditions precedent to the award of a contract.This document has been duly authorized by the governing body of the respondent
nd I(the person signing below)am authorized to represent the respondent.
•2)AUTHORIZED REPRESENTATIVE Check If change 0 13)SIGNATURE OF AUTHORIZED REPRESENTATIVE
ame: Judith A. Smith, RN, BSN q,atithek 4 .,if
`tie`Director of Health Phone:409-983-8896 ea 05/13/2019
DocuSign Envelope ID:C09140A3-7664-4220-8758-D5CAEOAE2B82
•
Office of Primary and Specialty Health
TEXAS
v : Primary Health Care Contractor Renewal for Financial Assistance
v Health and Human
:J-S. t: Services
INSTRUCTIONS FOR FORM A-1: FACE PAGE
This form provides basic information about the respondent and the proposed project with the Texas Health and
Human Services Commission (HHSC), 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
HHSC 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://fedgov.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
1
DocuSign Envelope ID:C09140A3-7664-4220-875B-D5CAEOAE2B82
Non-Profit Corporation or For-Profit Corporation, provide the 10-digit charter number assigned by the
Secretary of State.
8. PROPOSED BUDGET AND PERIOD- Enter the budget amount and budget period for this renewal.
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. PHC PROJECT CONTACT PERSON - Enter the name, phone,fax, and e-mail address of the person
responsible for the proposed PHC project.
11. FINANCIAL OFFICER- Enter the name, phone,fax, and e-mail address of the person responsible for the
financial aspects of the proposed project.
12. AUTHORIZED REPRESENTATIVE- Enter the name,title, phone, 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 HHSC/DSHS.
13. SIGNATURE OF AUTHORIZED REPRESENTATIVE—The person authorized to represent the respondent
must sign in this blank.
14. DATE-Enter the date the authorized representative signed this form.
2
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
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 El R Counties 0 R Counties El R Counties Ell R Counties El 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 0 01 Hood 0 03 McMullen 0 11 Somervell 0 03
Smith
Atascosa 0 08 Delta 0 04 Hopkins 0 04 Medina 0 08 Starr 0 11
Austin 0 06 Denton ❑ 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 ❑ 08 Dimwit ❑ 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- bion ❑ 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 lit 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 Kames 0 08 Oldham 0 01 Upton 0 09
Burleson 0 07 Foard 0 02 Kaufman 0 03 Orange 0 05 Uvalde 0 08
Bumet 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 El 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 0 07 Lee 0 07 Reeves 0 09 Williamson 0 07
Coleman 0 02 Guadalupe 0 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 0 01 Rockwall 0 03 Wood 0 04
Coma! 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 ❑ 02
Cooke ❑ 03 Hardin 0 05 Lubbock 0 01 Sabine ❑ 05 -Z-
Coryell ❑ 07 Harris 0 06 Lynn ❑ 01 San ❑ 05 Zapata ❑ 11
Augustine
Cottle 0 02 Harrison ❑ 04 -M- San Jacinto 0 05 Zavala 0 08
Crane ❑ 09 Hartley 0 01 Madison 0 07 San Patriclo 0 11
Crockett 0 09 Haskell 0 02 Marion 0 04 San Saba 0 07
DocuSign Envelope ID:C09140A3-7684-4220-875B-D5CAEOAE2B82
Office of Primary and Specialty Health
TEXAS
Primary Health Care Contractor Renewal for Financial Assistance
4 I:1 Health and Human
• t'=' Services FORM B: CONTACT PERSON INFORMATION
Legal Business City of Port Arthur
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. *
Name Judith A. Smith Mailing Address(street,city,county,state&zip)
Title Director of Health Services
449 Austin Avenue
Phone 409-983-8832 Ext: Port Arthur, TX, 77640
Fax 409-983-1530 Jefferson County
Email judith.smith@portarthurtx.gov
Name Latasha Mayon, RN, BSN Mailing Address(street, city,county,state&zip)
Title Assistant Director of Health
449 Austin Avenue
Phone 409-983-8862 Ext: Port Arthur, TX, 77640
Fax 409-984-9093 Jefferson County
Email latasha.mayon@portarthurtx.gov
Name Rosaland Shelton Mailing Address(street,city,county,state&zip)
Title Eligibility Worker
449 Austin Avenue
Phone 409-983-8896 Ext. Port Arthur, TX, 77640
Fax 409-983-1530 Jefferson County
Email rosaland.shelton@portarthurtx.gov
Name Erika Flores Mailing Address(street,city,county,state&zip)
Title Administrative Aide
449 Austin Avenue
Phone 409-983-8864 Ext. Port Arthur, TX, 77640
Fax 409-983-5012 Jefferson County
Email erika.flores@portarthurtx.gov
Name Mailing Address(street, city,county, state&zip)
Title
Phone Ext.
Fax
Email
DocuSign Envelope ID:C09140A3-7664-4220-8758-D5CAEOAE2B82
�-� ' TEXAS Office of Primary and Specialty Health
ildiPrimary Health Care Contractor Renewal for Financial Assistance
iV Health and Human
•:,�i !:1 Services
• ... • FORM E: PERFORMANCE MEASURES
Legal Business City of Port Arthur
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 HHSC. 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 HHSC expects that by the end of the contract period the
contractor will have met it.
Reimbursement for PHC Services
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. 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.
Total number of unduplicated clients = The estimated total number of unduplicated HHSC PHC clients
to whom the agency will provide primary health care services.
Table 1: PHC Clients
TOTAL number of Unduplicated HHSC PHC Clients to be provided services with 356
HHSC PHC funds: J V
Table 2: PHC Funds
TOTAL PHC Funding Amount Requested -(This includes ALL unduplicated PHC $
Clients to be served in Table 1) 62,300
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
Primary Health Care Contractor Renewal for Financial Assistance
FORM E: FY20 PERFORMANCE MEASURES - Page 2
Contractor must include the performance measures for FY20 budget. 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 FY20, 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 2020 Budget
Total Number of Unduplicated PHC Clients/Average Cost per Client/Total Amount
#Clients x Average Cost per Client=
Total#Unduplicated HHSC Clients Average Cost per Client Total Amount
356 $ 175.00 $ 62,300
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
vL� `'� TEXAS Office of Primary and Specialty Health
Primary Health Care Contractor Renewal for Financial Assistance
%J aV Health and Human
�. Services INSTRUCTIONS FOR FORM I: Primary Health Care Clinic Sites
Instructions:Complete a separate clinic site form for each existing or proposed clinic site for which FY18 and FY19
HHSC 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 HHSC 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 Name of the clinic as it will appear on the HHSC website locator. (The name
Website Locator should be recognizable to clients.)
Service Area List only the counties that will be served by that specific clinic site, and NOT all
counties served by the entire project. Note:Counties served by all clinics must
match counties checked on Form A-1: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.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#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 HHSC Contract
Manager in a timely manner. Programmatic or operational changes must be made in accordance with requirements
outlined in the contract.
DocuSign Envelope ID:C09140A3-7664-4220-875B-D5CAEOAE2B82
/e/ • TEXAS Office of Primary and Specialty Health
v Primary Health Care Contractor Renewal for Financial Assistance
4 If Health and Human
•..�. Services FORM I: Primary Health Care Clinic Sites
Legal Business Name Cityof Port Arthur
of Contractor: Clinic Site# of
Instructions: CLINIC SITE INFORMATION: Complete this form for EACH clinic site that will provide PHC
services September 15t for FY20. 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 Suite
449 Austin Avenue
City County Zip Code HSR:
Port Arthur Jefferson 77640
Clinic APPOINTMENT Phone No.:
409-983-8896
Clinic PRIMARY Phone No.:
409-983-8878
Service Area
(Counties to be served Jefferson
by this clinic site):
Contact Person:
Rosaland Shelton
Pharmacy License No.: Class: TPI#: NPI#:
Subcontractor Site: Mobile Site:
Yes n No Q✓ Yes No ✓❑
CLINIC HOURS
DAY HOURS OF OPERATION #MONTHLY
CLINICS
Morning Afternoon Evening(after 5 p.m.)
From To From To From To
MONDAY 8:00 a.m. 12:00 p.m. 1:00 p.m. 5:00 p.m. 4
TUESDAY 8:00 a.m. 12:00 p.m. 1:00 p.m 5:00 p.m. 4
WEDNESDAY 8:00 a.m. 12:00 p.m. 1:00 p.m 5:00 p.m. 4
THURSDAY 8:00 a.m. 12:00 p.m. 1:00 p.m 5:00 p.m. 4
FRIDAY 8:00 a.m. 12:00 p.m. 1:00 p.m 5:00 p.m. 4
SATURDAY 0
SUNDAY 0
TOTAL
HRS/MONTH
TOTAL O
CLINICS/MONTH
DocuSign Envelope ID:C09140A3-7664-4220-8758-D5CAEOAE2B82
'•� TEXAS Office of Primary and Specialty Health
t'+1 Primary Health Care Contractor Renewal for Financial Assistance
�` t Health and Human
. �' ' Services
FORM J: FY20 Primary Health Care Program Certification
This certification pertains to the following Primary Health Care (PHC) Program Applicant:
Applicant Name:
City of Port Arthur
Federal Tax ID No.: NPI No.:
1746001885001
Applicant's Primary Billing Address:
449 Austin Avenue
Telephone No.:
409-983-8896
Applicant's Primary Physical 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.
FY20 PHC Contractor Renewal Form J—Page 1
DocuSign Envelope ID:C09140A3-76B4-4220-8758-D5CAEOAE2B82
1%� ��� TEXAS Office of Primary and Specialty Health
v Primary Health Care Contractor Renewal for Financial Assistance
v ,'v
`�, Health and Human
� Services FORM J: FY20 Primary Health Care Program Certification
My name is Judith A. Smith . I am the provider or, if the provider is an
organization, I am the provider's Director of Health (title or position). I am of sound mind,
capable of making this certification,and I am personally acquainted with the facts stated here. If I 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 "1"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 "I" 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. II, at I1-63).
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, I 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.
I affirm that this statement is true and correct.
FY20 PHC Contractor Renewal Form J—Page 2
DocuSign Envelope ID:C09140A3-7664-4220-8758-D5CAEOAE2B82
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.
O 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.
0 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 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.
O I affirm that this statement is true and correct.
FY20 PHC Contractor Renewal Form J—Page 3
DocuSign Envelope ID:C09140A3-7664-4220-8758-D5CAEOAE2B82
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.
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.
O 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 Primary Health Care 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 Primary Health
Care 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;
FY20 PHC Contractor Renewal Form.)—Page 4
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
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.
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:09/01/2019 through 08/31/2020.
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
4GV,� ,
��Gi�t�7CJ
uidu
Print ame
;Judith A. Smith, RN, BSN
I True I Date
!Director of Health 105/13/2019
FY20 PHC Contractor Renewal Form.1—Page 5
DocuSign Envelope ID:C09140A3-7684-4220-875B-D5CAEOAE2B82
Attachment D - FY 2020 Budget
Documents
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
FORM F:BUDGET SUMMARY(REQUIRED)
Legal Name of Respondent: CITY OF PORT ARTHUR
Total Primary Health HHSC Share Patient Co-Pays
Budget Categories Care Budget Categorical Award To Be Collected
(1) (2) (3)
A. Personnel $35,736 $35,736
B. Fringe Benefits $10,817 $10,817 $0
C. Travel $639 $639 $0
D. Equipment $0 $0 $0
E. Supplies $0 $0 $0
F. Contractual $15,108 $15,108
G. Other $0 $0 $0
H. Total Direct Costs $62,300 $62,300 $0
I. Indirect Costs $0
Total(Sum of H and
I $62,300 $62,300 $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 $35,736 $35,736 Fringe Benefits $10,8171 $10,817
Travel $639 $639 Equipment $0 $0
Supplies $0 $0 Contractual $15,108 $15,108
Other $0 $0 Indirect Costs $0 $0
TOTAL FOR: 'Distribution Totals $62,3001BudgetTotal $62,300
Revised:11/18/2009
DocuSign Envelope ID.C09140A3-76B4-4220-875B-DSCAEOAE2B82
FORM F-1:PERSONNEL Budget Category Detail Form
Legal Name of Respondent: CITY OF PORT ARTHUR
PERSONNEL Certification or Total Average Number Salary/Wages
Functional Title+Code Vacant License(Enter NA if Monthly of Requested for
E=Existing or P=Proposed Y/N Justification FTE's not required) Salary/Wage Months Project
Eligibility Billing Clerk(E) N Responsible for the Reports and Billing 1 N/A $2,978.00 12 $35,736
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
TOTAL FROM PERSONNEL SUPPLEMENTAL BUDGET SHEETS $0
ISalaryWage Total $35,736
FRINGE BENEFITS Itemize the elements of fringe benefits in the space below:
FICA 7.65, INSURANCE 22%, WORKER'S COMP 0.15%,TMRS.32%, TERMINATING PAY.15%
Fringe Benefit Rate% 30.27%
Fringe Benefits Total $10,817
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-7684-4220-875B-DSCAEDAE2B82
FORM F-2:TRAVEL Budget Category Detail Form
Legal Name of Respondent: CITY OF PORT ARTHUR
Conference/Workshop Travel Costs
Description of Number of
Conference/Workshop Justification Location Travel Costs
City/State Days/Employees
2 Days,1 night Mileage
for for 1 Airfare
DSHS PHC Eligibility Training To Receive PHC updates Austin employee. Meals $88
Includes car Lodging $300
Other Costs $135
rental and gas Total $523
Mileage
Airfare
Meals
Lodging
Other Costs
Total
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/Workshop Travel $523
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-76B4-4220-875B-DSCAEOAE2B82
Other/Local Travel Costs I
Number of Mileage
Justification Miles Mileage Reimbursement Rate Cost Other Costs Total
(a) (b) (a)+(b)
PHC Program outreach
200 $0.580 $116 $116
$0 $0
$0 $0
$0 SO
$0 $0
$0 $0
$0 $0
TOTAL FROM TRAVEL SUPPLEMENTAL OTHER/LOCAL TRAVEL COSTS BUDGET SHEETS $0
Total for Other/Local Travel $116
Other/Local Travel Costs: $116 Conference/Workshop Travel Costs: $523 Total Travel Costs: $639
Indicate Policy Used: Respondent's Travel Policy State of Texas Travel Policy
Revised:7/6/2009
DocuS:gn Envelope ID:C09140A3-7684-4220-8758-D5CAEOAE2B82
FORM F-3: EQUIPMENT AND CONTROLLED ASSETS Budget Category
Detail Form
Legal Name of Respondent: CITY OF PORT ARTHUR
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 Cost Per
Description of Item Purpose&Justification of Units 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
DocuSign Envelope ID:C09140A3-7664-4220-875B-D5CAEOAE2B82
FORM F-4:SUPPLIES Budget Category Detail Form
Legal Name of Respondent: CITY OF PORT ARTHUR
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.a of boxes&cost/box)] Purpose&Justification Total Cost
TOTAL FROM SUPPLIES SUPPLEMENTAL BUDGET SHEETS $0
Total Amount Requested for Supplies: $0
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-7684-4220-8758-D5CAEOAE2B82
FORM F-5:CONTRACTUAL Budget Category Detail Form
Legal Name of Respondent: CITY OF PORT ARTHUR
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
PAYMENT q of Months, PAYMENT 0.e.,
CONTRACTOR NAME DESCRIPTION OF SERVICES Justification (i.e.,Monthly, Hours,Units, TOTAL
(Agency or Individual) (Scope of Work)
Y hourly rate,unit
Hourly,Unit, etc. rate,lump sum
Lump Sum) amount)
Lab Services for PHC clients Provides lab tests outside the scope
Lab Corp of the city's lab. Monthly 12 $1,259.00 $15,108
$0
$0
$0
$0
$0
$0
$0
TOTAL FROM CONTRACTUAL SUPPLEMENTAL BUDGET SHEETS $0
Total Amount Requested for CONTRACTUAL: $15,108
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
FORM F-6:OTHER Budget Category Detail Form
Legal Name of Respondent: CITY OF PORT ARTHUR
Description of Item
[If applicable,include quantity and cost/quantity(i.e.d of units&cost per
unit)] Purpose&Justification Total Cost
TOTAL FROM OTHER SUPPLEMENTAL BUDGET SHEETS SO
Total Amount Requested for Other: $0
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-7664-4220-8758-D5CAEOAE2B82
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-
la 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.
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
DocuSign Envelope ID:C09140A3-7684-4220-875B-D5CAEOAE2B82
FORM F-1:PERSONNEL Budget Category Detail Form(Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
PERSONNEL Certification or Total Average Number Salary/Wages
Functional Title+Code Vacant License(Enter NA if Monthly of Requested for
E=Existing or P=Proposed Y/N Justification FTE's not required) Salary/Wage Months Project
$0
$0
$0
$0
So
So
So
So
So
$o
So
So
$o
$o
SalaryWage Total so
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-76B4-4220-875B-DSCAEOAE2B82
FORM F-1:PERSONNEL Budget Category Detail Form(Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
PERSONNEL Certification or Total Average Number Salary/Wages
Functional Title+Code Vacant License(Enter NA if Monthly of Requested for
E=Existing or P=Proposed Y/N Justification FTE's not required) Salary/Wage Months Project
$0
$0
$o
so
s0
$o
$o
$o
So
$o
$o
$o
$o
$o
SalaryWage Total $0
Revised:7/6/2009
DocuSign Envelope ID:C09140A3 7684-4220-875&DSCAEOAE2B82
FORM F-2:TRAVEL Budget Category Detail Form(Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
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 SO
Mileage
Airfare
Meals
Lodging
Other Costs
Total SO
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Mileage
Airfare
Meals
Lodging
Other Costs
Total SO
Mileage
Airfare
Meals
Lodging
Other Costs
Total $0
Total for Conference/Workshop Travel $0
Other/Local Travel Costs I
Number of I I Mileage I I Revised:7/6/2609
DocuSign Envelope ID:C09140A3-76B4-4220-875B-DSCAEOAE2B82
Justification Miles Mileage Reimbursement Rate I Cost I Other Costs I Total
(a) (b) (a)+(b)
$0 $0
$0 $0
$o So
$0 $0
$0 $0
$o $o
$0 $0
$0 $0
$0 $0
Total for Other/Local Travel $0
Other/Local Travel Costs: $0 Conference/Workshop Travel Costs: $0 Total Travel Costs: $0
Revised:7/6/2009
DaceSign Envelope ID:C09140A5-7684-4220-875B-DSCAEOAE2B82
FORM F-2:TRAVEL Budget Category Detail Form(Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
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/Workshop Travel $0
Other/Local Travel Costs I
Number of I I Mileage I I Revised:7/6/2009
DocuSign Envelope ID:C09140A3-7664-4220-875B-D5CAEOAE2B82
Justification MilesMileage Reimbursement Rate Cost Other Costs Total
l (a) (b) (a)+(b)
SO So
SO $0
So $O
So $o
So So
So $o
So $o
So $o
So So
Total for Other/Local Travel 50
Other/Local Travel Costs: $0 Conference/Workshop Travel Costs: $0 Total Travel Costs: $0
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-7684-4220-8758-D5CAEOAE2B82
FORM F-3: EQUIPMENT AND CONTROLLED ASSETS Budget Category
Detail Form (Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
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 Cost Per
Description of Item Purpose&Justification of Units Unit Total
$0
So
So
So
So
$0
$0
$0
$0
So
$0
$0
$0
$0
$0
$o
$0
$0
Total Amount Requested for Equipment: $0
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-7684-4220-875B-DSCAEOAE2B82
FORM F-3: EQUIPMENT AND CONTROLLED ASSETS Budget Category
Detail Form(Supplemental)
Legal Name of Respondent:
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 Cost Per
Description of Item Purpose&Justification of Units 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
DocuS,gn Envelope ID.C09140A3-7664-4220-8758-D5CAEOAE2B82
FORM F-4: SUPPLIES Budget Category Detail Form(Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
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
[I'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
DocuSign Envelope ID:C09140A3-76B4-4220-875B-DSCAEOAE2B82
FORM F-4:SUPPLIES Budget Category Detail Form (Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
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/boxf Purpose&Justification Total Cost
Total Amount Requested for Supplies: $0
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
FORM F-5: CONTRACTUAL Budget Category Detail Form(Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
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.
RATE OF
CONTRACTOR NAME DESCRIPTION OF SERVICES METHOD OF JJ of Months, PAYMENT
(Agency or Individual) (Scope of Work) Justification PAYMENT (i.e. Hours,Units, (i.e.hourly rate, TOTAL
Monthly,Hourly, etc. unit rate,lump
Unit,Lump Sum) sum amount)
$0
$0
$0
$0
$0
•
$0
$0
$0
$o
$o
Total Amount Requested for CONTRACTUAL: $0
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-76B4-4220-8758-D5CAEOAE2B82
FORM F-5: CONTRACTUAL Budget Category Detail Form (Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
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.
RATE OF
CONTRACTOR NAME DESCRIPTION OF SERVICES METHOD OF #of Months, PAYMENT
or Individual) Justification PAYMENT (i.e. Hours,Units, (Le.hourly rate, TOTAL
(Agency (Scope of Work)
Monthly,Hourly, etc. unit rate,lump
Unit,Lump Sum) sum amount)
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
Total Amount Requested for CONTRACTUAL: $0
Revised:7/612009
DocuSign Envelope ID:C09140A3-76B4-4220-8758-D5CAEOAE2B82
FORM F-6:OTHER Budget Category Detail Form(Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
vescl ipsion or item
[If applicable,include quantity and cost/quantity(i.e.N of units&
cost/unit)] Purpose&Justification Total Cost
Total Amount Requested for Other: $0
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-7684-4220-875B-D5CAEOAE2B82
FORM F-6:OTHER Budget Category Detail Form (Supplemental)
Legal Name of Respondent: CITY OF PORT ARTHUR
1.1e5Lrrpuutt or nem
Of applicable,include quantity and cost/quantity(i.e.a of units&
cost/unit)] Purpose&Justification Total Cost
Total Amount Requested for Other: $0
Revised:7/6/2009
DocuSign Envelope ID:C09140A3-76B4-4220-875B-D5CAEOAE2B82
FORM F-7 Indirect Costs
Legal Name of Respondent: CITY OF PORT ARTHUR
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 RATE:
cognizant agency or state single audit coordinating agency. Expired rate BASE:
agreements are not 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 RATE:
service cost rate or indirect cost rate based on a rate proposal prepared in TYPE:
accordance with OMB Circular A-87. Attach a copy of Certification of Cost BASE:
Allocation Plan or 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
X submitted to HHSC within 60 days of the contract start date. The CFPM is
available on the following Internet web link:
http://www.dshs.state.tx.us/contracts/
GO TO PAGE 2(below)
Revised:7/6/2009
DocuSign Envelope ID.C09140A3-7684-4220-8758-DSCAEOAE2B82
Page 2, FORM F-7 Indirect Costs
tf 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
Dom
•sEcuitUo
Certificate Of Completion
Envelope Id:C09140A376B44220875BD5CAE0AE2B82 Status:Sent
Subject:Amending$326,900; 2016-048585-002;City of Port Arthur A-4;MSS/HDIS/HDS/OPSH Primary Health Care
Source Envelope:
Document Pages: 76 Signatures:0 Envelope Originator:
Certificate Pages:2 Initials:0 Texas Health and Human Services Commission
AutoNav:Enabled 1100 W.49th St.
Envelopeld Stamping:Enabled Austin,TX 78756
Time Zone:(UTC-06:00)Central Time(US&Canada) PCS_DocuSign@hhsc.state.tx.us
IP Address: 167.137.1.13
Record Tracking
Status:Original Holder:Texas Health and Human Services Location: DocuSign
7/23/2019 12:56:21 PM Commission
PCS_DocuSign@hhsc.state.tx.us
Signer Events Signature Timestamp
Rebecca Underhill Sent:7/23/2019 1:01:26 PM
rebecca.underhill@portarthurtx.gov
Interim City Manager
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Lindsay Rodgers
Lindsay.Rodgers@hhsc.state.tx.us
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Sherry Mojica COPIED Sent:7/23/2019 1:01:25 PM
sherry.mojica@hhsc.state.tx.us
Contract Coordinator
Texas Health and Human Services Commission
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Meisha Scott Sent:7/23/2019 1:01:25 PM
Meisha.Scott@hhsc.state.tx.us COPIED
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Carbon Copy Events Status Timestamp
Not Offered via DocuSign
Marissa Acosta COPIED Sent:7/23/2019 1:01:25 PM
marissa.acosta05@hhsc.state.tx.us
Security Level: Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Judith Smith Sent:7/23/2019 1:01:26 PM
judith.smith@portarthurtx.gov COPIED Viewed: 7/23/2019 2:22:07 PM
Director of Health Services
City of Port Arthur
Security Level:Email,Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps
Envelope Sent Hashed/Encrypted 7/23/2019 1:01:26 PM
Payment Events Status Timestamps