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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AMENDMENT I TO AGREEMENT THIS AMENDMENT,hereinafter referred to as Amendment I,is made and entered into this day of ,2016,by and between the COUNTY OF FRESNO,a Political Subdivision of the State of California,hereinafter referred to as “COUNTY”,and each PROVIDER listed in Revised Exhibit A,“List of Providers”,attached hereto and by this reference incorporated herein,collectively hereinafter referred to as “PROVTDER(s)”and such additional PROVIDER^)as may,from time to time during the term of this Agreement,be added by COUNTY’S Department of Behavioral Health Director,or designee.Reference in this Amendment to “parties”shall be understood to refer to COUNTY and each individual PROVIDER,unless otherwise specified. WHEREAS,the parties entered into that certain Agreement,identified as COUNTY Agreement No.15-247,effective July 1,2015,whereby PROVIDERS agreed to provide specialty mental health services to certain Medi-Cal beneficiaries;and. WHEREAS,the parties desire to amend COUNTY Agreement No.15-247,regarding changes as stated below and restate the Agreement in its entirety. NOW,THEREFORE,for good and valuable consideration,the receipt and adequacy of which is hereby acknowledged,the parties agree as follows: 1.That the existing COUNTY Agreement No.15-247,Paragraph Five (5),beginning on Page Eight (8),Line Ten (10),with the number “2.”and ending on Page Eight (8),Line Eleven (11) with the word “time;”be deleted and the following inserted in its place: “2.The service is Covered/Billable Service under the Mental Health Plan according to the terms and conditions set forth in the State DHCS Mental Health Services Division Medi-Cal Billing Manual in effect at that time;” 2.That the existing COUNTY Agreement No.15-247,Paragraph Five (5),beginning on Page Ten (10),Line Nineteen (19),with the word “During”and ending on Page Ten (10),Line Twenty One (21),with the word “Agreement”be deleted. 3.That the existing COUNTY Agreement No.15-247,Paragraph Five (5),beginning on Page Ten (10),Line Twenty Seven (27),with the word “PROVIDER(s)”and ending on Page Eleven (11),Line Five (5),with the word “services.”be deleted. -I - COUNTY OF FRESNO Fresno,CA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 4.That the existing COUNTY Agreement No.15-247,Paragraph Eight (8),beginning on Page Twelve (12),Line Seventeen (17),with the word “These”and ending on Page Twelve (12),Line Twenty (20),with the word “Agreement”be deleted and the following inserted in its place: “These same provisions shall apply to the deletion of any PROVIDER(s)contained in Revised Exhibit A,except that deletions shall be made by mutual written consent between COUNTY’S DBH Director,or designee,and the specific PROVIDER(s)to be deleted or shall be in accordance with Section 5 of this Agreement.” 5.That the existing COUNTY Agreement No.15-247,Paragraph Twelve (12),beginning on Page Fourteen (14),Line Nine (9),with the word “PROVIDER(s)”and ending on Page Fourteen (14),Line Twelve,with the word “Agreement”be deleted and the following inserted in its place: “This section left intentionally blank”. 6.That the existing COUNTY Agreement No.15-247,Paragraph Twelve (12),beginning on Page Fourteen (14),Line Fourteen (14)with the word “PROVIDER(s)”and ending on Page Fourteen (14),Line Seventeen (17),with the word “Policy”be deleted and the following inserted in its place: “This section left intentionally blank”. 7.That the existing COUNTY Agreement No.15-247,Paragraph Twelve (12),beginning on Page Fourteen (14),Line Nineteen (19),with the word “PROVIDER(s)”and ending on Page Fourteen (14),Line Nineteen (19),with the word “thereon”be deleted and the following inserted in its place: “This section left intentionally blank”. 8.That the existing COUNTY Agreement No.15-247,Paragraph Fifteen (15),beginning on Page Sixteen (16),Line Twenty Five (25),with the letter “A.”and ending on Page Eighteen (18), Line Twenty Four (24),with the word “Agreement.”be deleted and the remaining subsections in the original Agreement Paragraph Fifteen (15)shall be re-numbered sequentially to be identified as subsections “A”through “B”. 9.That the existing COUNTY Agreement No.15-247,Paragraph Nineteen (19),beginning on Page Nineteen (19),Line Twenty Three (23),with the word “PROVIDER(s)”and ending on Page 2 COUNTY OF FRESNO Fresno,CA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Twenty (20),Line Seven (7),with the word “designee”be deleted and the following inserted in its place: “PROVIDER(s)shall be required to maintain Medi-Cal provider certification by Fresno County.PROVIDER(s)must meet Medi-Cal provider standards as listed in Revised Exhibit F,“Medi- Cal Provider Standards”,attached hereto and by this reference incorporated herein and made part of this Agreement.It is acknowledged that all references to Provider and/or Medi-Cal Provider in Revised Exhibit F shall refer to PROVIDER(s).In addition ,PROVlDER(s)shall inform every client of their rights under the COUNTY’S Mental Health Plan as described in “Fresno County Mental Health Plan Grievances and Appeals Process”Revised Exhibit G ,attached hereto and by this reference incorporated herein and made part of this Agreement.PROVIDER(s)shall also file an incident report for all incidents involving clients,following the Protocol for Completion of Incident Report and using the Worksheet identified in the “Fresno County Mental Health Plan Incident Reporting”,Revised Exhibit H,attached hereto and by this reference incorporated herein and made part of this Agreement, or a protocol and worksheet presented by PROVIDER(s)that is accepted by COUNTY’S DBH Director,or designee.” 10.That the existing COUNTY Agreement No.15-247,Paragraph Twenty Three (23), beginning on Page Twenty Two (22),Line Nineteen (19),with the number “23.”and ending on Page Twenty Four (24),Line Twenty Eight (28),with the word “obligations.”be deleted in its entirety.The remaining paragraphs in the original Agreement 15-247 shall be re-numbered sequentially to read paragraphs 23 through 38. 11.That the existing COUNTY Agreement No.15-247,Paragraph Twenty Five (25), beginning on Page Twenty Six (26),Line Three (3),with the word “In”and ending on Page Twenty Six (26),Line Eleven (11),with the word “accordingly”be deleted and the following inserted in its place: “In compliance with the State mandated Culturally and Linguistically Appropriate standards as published by the Office of Minority Health,PROVIDER(s)must submit to COUNTY for approval,within sixty (60)days from date of contract execution,PRO VIDER(s)plan to address all fifteen (15)national cultural competency standards as set forth in the “National Standards on Culturally 3 COUNTY OF FRESNO Fresno,CA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 and Linguistically Appropriate Services (CLAS)”.COUNTY’S annual on-site review of PROVIDER(s)shall include collection of documentation to ensure all national standards are implemented.As the national competency standards are updated,PROVIDER (s)plan must be updated accordingly.” 12.That the existing COUNTY Agreement No.15-247,Paragraph Twenty Seven (27), beginning on Page Twenty Seven (27),Line Seventeen (17),with the letter “B.”and ending on Page Twenty Eight (28),Line One (1)with the word “Collector.”be deleted in its entirety.The remaining subsection in the original Agreement 15-247 shall be re-lettered sequentially to read “B”. 13.That all references in the existing COUNTY Agreement No.15-247 to “Exhibit A”shall be changed to read “Revised Exhibit A”where appropriate,attached hereto and incorporated herein by this reference. 14.That all references in the existing COUNTY Agreement No.15-247 to “Exhibit F”shall be changed to read “Revised Exhibit F”where appropriate,attached hereto and incorporated herein by this reference. 15.That all references in the existing COUNTY Agreement No.15-247 to “Exhibit G”shall be changed to read “Revised Exhibit G”where appropriate,attached hereto and incorporated herein by this reference. 16.That all references in the existing COUNTY Agreement No.15-247 to “Exhibit H”shall be changed to read “Revised Exhibit H”where appropriate,attached hereto and incorporated herein by this reference. 17.That the existing COUNTY Agreement No.15-247,Paragraph Thirty Three (33), beginning on Page Thirty Four (34),Line One (1),with the word “Within”and ending on Page Thirty Four (34),Line Six (6),with the word “I”,be deleted and the following inserted in its place: “Within ten (10)days after each incident or complaint affecting COUNTY-sponsored clients,PROVIDER(s)shall provide COUNTY with information relevant to the complaint, investigative details of the complaint,the complaint and PROVIDER(s)disposition of,or corrective action taken to resolve the complaint.In addition,PROVIDER(s)shall inform every client of their rights as set forth in Revised Exhibit H.PROVIDER(s)shall file an incident report for all incidents -4 - COUNTY OF FRESNO Fresno,CA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 involving clients,following the Protocol and using the Worksheet identified in Revised Exhibit H.” 18.That all references to “CONTRACTOR(s)”in the existing COUNTY Agreement No. 15-247 to Exhibit C,Exhibit D,Exhibit E,and Exhibit K ,attached hereto and incorporated herein by this reference,shall be understood to refer to “PROVIDER(s)”as defined in “Revised Exhibit A”. COUNTY and PROVIDER(s)agree that this Amendment I is sufficient to amend the Agreement;and that upon execution of this Amendment I,the Agreement and Amendment I together shall be considered the Agreement. The Agreement,as hereby amended ,is ratified and continued.All provisions,terms, covenants,conditions and promises contained in the Agreement ,and not amended herein,shall remain in full force and effect.This Amendment I shall become effective upon execution by all parties. Ill III III III III III III III III III III III III III III III III III -5 - COUNTY OF FRESNO Fresno,CA 1 fN WITNESS WHEREOF, the parties hereto have executed this Amendment I to 2 Agreement No. 15-247 as of the day and year first hereinabove written. 3 ATTEST: 4 PROVIDERS: 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 PLEASE SEE SIGNATURE PAGES ATTACHED COUNTY OF FRESNO -6 - BERNICE E. SEIDEL, Clerk Board of Supervisors PLEASE SEE ADDITIONAL SIGNATURE PAGE ATTACHED COUNTY OF FRESNO Fresno, CA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 APPROVED AS TO LEGAL FORM: DANIEL C.CEDERBORG,COUNTY COUNSEL By :A APPROVED AS TO ACCOUNTING FORM: VICKI CROW,C.P.A.,AUDITOR-CONTROLLER/ TREASURER-TAX COLLECTOR REVIEWED AND RECOMMENDED FOR APPROVAL: By 'iMl&cJxfc Dawan Utecht,Director Department of Behavioral Health Fund /Subclass:0001/10000 Organization:56302666 Account/Program:7223/0 7 COUNTY OF FRESNO Fresno,CA 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Yuleen Al-Saoudi By:Jf CL fMZU Print Name:i U |g g /1 A I 'Shf )\AA Title:MM £T v (oDate:l In, Mailing Address: 516 Villa Suite #3 Clovis,CA 93612 Phone No .:{5 Sty ^~1 -3 % FAX:No.: Contact: COUNTY OF FRESNO Fresno,CA 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Dolores G.Amato By:V Print Name:(~7~fj~I'Fuxfs Title:A Z C q (AX <?ci OlOAV t aq g, 'Su/'H t ~C K-r^ Date:~~7 ~t (c Mailing Address: 6777 N.Willow Ave #144 Fresno,CA 93710 Phone No.:S~S~°i -23??"72-3>0 FAX :No,_730 -735*7 Contact: COUNTY OF FRESNO Fresno,CA 10 1 2 3 4 5 6 .7 8 '9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 PROVIDER:Jane Amling-Heiken BV:^LAyix )fhy^Ah }/t )(WulCMLZ Print Name:OOlAP.ftfpl l f\A 14-Pxk.£/U5- Title:^T)LiW 5^T Date:Ipl 1 v)\\lo Mailing Address: 5464 N.Palm #B Fresno,CA 93704 Phone No.:65 ^'"Sk-1 *9.^>40 FAX:No.:66 4 •Wl *\DO M Contact:s)(XAt H"6»^t -O AGREEMENT 15-247 AMENDMENT I COUNTY OF FRESNO Fresno,CA -11- 1 2 3 4 5 6 3 9 10 11 12 13 14 15 16 17 13 19 20 21 22 23 24 25 26 27 28 PROVIDER: By ^-3 /4 C-iil/iiQgi \~7 -g rV'f -e,^, Print Name:vj i j <H~~i n 6 .A c Ut .U~?Fr 1 *tle:TTrrVSgC^./t,lau,l ly'IliQLel^ii ~t Dale:?/?/f 1 AGREEMENT 15 -247 AMENDMENT I Mailing Address: 471 )Cp •n i le r /v e $Z. Pw>suO .C 4 73?^ Phone No:v/57 ~7 Q*?Tj7 03 Fax No:557-7 77?~*3,071 Contact: COUNTY OF FRESNO Fresno,CA -12- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: By Print Name:EljCa AVjna Title:1 M FT Date:08/18/16 Mailing Address: 614 N st Sanger CA Phone No:55a 9976577 Fax No: Contact: COUNTY OF FRESNO Fresno,CA -13- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1/2016 16:39 RECEIVED 08/19 /2016 03:41PMm P.001/001 PROVIDER:VirgMa Bergstrom '/Ap'r*w RECEIVED AUG 1 8 2016 FRESNO COUNTYMENTALHEALTH AGREEMENT 15-247 AMENDMENT I ElintNaif:(/_/W a (ZZ&ft ,. ritk:At ~{pg /mt 7 ^/A nan of Board,or Prtstd P'JkR'Z^U)}£ Chairman of Board,or President or say Vice President Mailing Address: CVi*g /V -QOIM &££ ,/.s-.<rq )/?*?«#? »»>*,T^-r?Y gJglL. Phone No.: Contact: -l -COUNTY OF FRJSSNO Fiwno.CA -14- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: Print Name:Articnaie&odansnyr Title:Licensed irerrageandfemV therapist Date:irm Mailing Address: 3723edakotaave fresroca937n Phone No:559336-3326 Fax No:5932255369 Contact:AnfatetteBrocfcre COUNTY OF FRESNO Fresno,CA -15- 1. 2 3 4 5 6 S 9 10 11 12 1,3 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT l PROVIDER :Dianne A .Burkes-Bell \U Print Name:J3 (*S (J C Title:L *f A »T *T full Date:a .x ijp Mailing Address: 'thiannt hiidtfb 3 ~bdi ji /AVf JdiSAJ:-Tallhfpck-A- Ti-a.5 iX) | Co -i 57 3 o Cba ^rASS Locfrli w ‘ 5010^fjrsvtp ,pc;.4 yv ° Phone No:3^6 ' Fax No:S'T^-'—S Q 2L2_ Contact :/?.?!^ -16- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER^Hector Cabrera By . Print Name:-W; Title: Dale-.ftlSVj? Mailing Address: 4 m A ).S 4- PA Phone NO:7 Uf )~l .Ll f,l Fax No: Contact: COUNTY OF FRESNO Fresno,CA -17- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: Print Name: H7 Title:' Date:£- Mailing Address: 4946?£FM 'W \&/ F^sno ,cTKiai Phone No:C ^S'—1 H \S~ Fax No:6*<T?g -g 4 4 4 Contact:c ^ujhVlA M COUNTY OF FRESNO Fresno ,CA -18- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RECEIVED AUG 1 8 2016 FRESNO COUNTY 'MENTAL HEALTH PROVIDER:Gabriele Case Bv (Oa.hfi 'eie && Print Name: Title:1L Date:£W /f ~// Mailing Address: ^.SUM Ar^. ’^Fr<e^Kol SA .9 ^7 // Phone No:2’2 L!-2 H S ~ Fax No:lH 7?-/g <£7_ h ca &elcStO(a )^ail aimContact: AGREEMENT 15-247 AMENDMENT I -19- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: Print Name: Title:UflPT Pate:l[gjjW Mailing Address:-1-70 E .fay S\M -\t!103 fmno GA Phone No:1 Fax No:feggQ 4(1%-W I Contact:i COUNTY OF FRESNO Fresno,CA -20- 1 2 3 A 5 6 7 8 9 10 11 12 13 1 A 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Dr .Claudia /Qerda By . Print Name:dd {(A Ul&JiStL fijfltu/oejiasf 'Title: Date:2.lit M . Mailing Address: {fill N -Utility )A ,u? - U2 Phone No:U ~/0 0 ^ Fax No:(<^) Contact:<A~_»-^,/^^Q . COUNTY OF FRESNO Fresno,CA -21- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 r ~' ? JUL 0 5 im AGREEMEN£f &i®40(.-ni TYAMENiMptr^^LTH PROVIDER:Andrew Constant By CoA^rpFv^|\iAC-S^'VA CC_ Print Name:Ar>R> Title:PrQ AOftTZ—] Date:\ Mailing Address: f .W \S.C A °!/9 Phone No:3 /9"<P 2-8 5IS1* Fax No: Contact: COUNTY OF FRESNO Fresno,CA 22 "Ifffi . 4 I 6 7 ft 1 ft S&§0 - 14 PROVIDER:C ynthia Dc Leon L 'ic -P I, Pnnt Name ^4 . j HiU-v*g?/K?>/£ t it 1 7 Mailm*!Address ggg|§ 516 Villa Suite #3 Clovis.CA 936 )2 i a.|: I i 23 8|4| s'I Phone No ?S*J /__!*rf Saj.~?7 7 / Contact; I Si flip; § st* AGRPEMl'NT 15-247 Vi I t I -isI ae p) ....'.I ;',I -’••. t'iu££.<A 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 O 3 <£-X 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Judith Dickey By:/$t/Acy Print Name:c )11(^1 //?cl)LClk^&f Title: Date:June 12 ,2016 Mailing Address: 5707 N.Palm #103 Fresno,CA 93704 Phone No.: FAX:No.: Contact: COUNTY OF FRESNO - Fresno,CA 24 1 2 3 4 5 6 7 8 9 10 11 12 13 i 4 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RECEIVED JUN 21 2016 FRESNO COUNTYMENTALHEALTH AGREEMENT 15-247 AMENDMENT I PROVIDER:Donald K.Farris Print Name;jyartcrJrJA**g Title: Date: Mailing Address: 3740 Circle Dr. Fresno,CA 93704-4765 Phone No.:^P ~7 S~C> FAX:No.:-jQr Contact:tf (T'/sjT COUNTY OF FRESNO Fresno,CA 25 1 AGREEMENT 15-247 AMENDMENT I2 3 4 5 6 7 a 9 10 PROVIDER:Catherine Garvey By:-r Print Name: Title: 11 12 13 14 Date:c?/3 //G 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Mailing Address: 5475 N.Fresno Street <,jijp./»( Fresno,CA 93710 PhoneNo.:7 FAX:No.:^/A Contact://)v COUNTY OF FRESNO Fresno,CA 26 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 PROVIDER:Dr.Howard Glidden By: Print Name:/-h*u/tss£& Title: Date:6?/"7 Mailing Address: 1660 E.Herndon #150 Fresno,CA 93720 Phone No.: FAX:No.: Contact: AGREEMENT 15-247 AMENDMENT I COUNTY OF FRESNO Fresno,CA -27- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: By Print Name:I 'vA 'HLo, Title:L M.'FT- Date:1r /i '/i 6 Mailing Address: 2-"])S O TVffTKe )0 CA Phone No:^I 7 -%^7 ^ Fax No:6^-3 ^3 -0731 Contact: COUNTY OF FRESNO Fresno,CA 28 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RECEIVED JUN 0 8 2016 FRESNO COUN TYMENTALHEALTH PROVIDER:Dr.Peggy Jackson-Salcedo AGREEMENT 15-247 AMENDMENT I Print Name:'P H-faCs ^L k.So|Q -^kN L.C R D O j ^ Title:PS^QESQ\O ^CQ,.Ll c .SV l ~l $ Date:uWlvt.lL Mailing Address: ISISP5-86-N.Van Ness Fresno,CA 93728 Phone No.:3 2 C}-0 d “l 4 FAX:No.:(5 5"^3 g.g‘ _^H 10 Contact:5 COUNTY OF FRESNO Fresno,CA -29- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROV By 'SSSUj-f t -— Print Name:-S&TRHAJKJ Title:<L./H F ( Date:%l 2>//A Mailing Address: Q ~~j \jJlLLQu^{^-0 pr (Li^ouii CiA HS &tZL Phone No:S 5 T~~^0 l-"9 S ZL Fax No: Contact:LCQ ) COUNTY OF FRESNO Fresno,CA -30- 08 /03 /2010 18:50 FAX 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 PROVIDER:f f ft.V\^"3 Rv ^f;vrirrr.l^C -s.co Print Name:^'ra.urfv A 1 -t.t.f tA ;^^ Title: Date:f -'Z -I U Mailing Address: Tum u>~.Uou Su \oz C Ip Cl'yC>C &.IX Phone No:<S <T J22 *i ~IS £.\ Fax No:«>S ISJfr Contact: Ht ‘1 AUG 0 8 'ZiiiS @ 002 sfiflt m;v.j AGREEMENT 15-247 AMENDMENT! ; i t i: : ! COUNTY OP FRESNO Fresno,CA 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Jeanette Lopez By:PJTTP * Print Name:B-O.flgjifEL ZJ2l no h'P .P )l £>C&2i e:Lfdtn £Jld Clin fOSo /v 5^0 fo.i LOOPK ^C Date:b j 5 ~^XO !5> Mailing Address: 2008 N.Fine #103 Fresno,CA 93727 Phone No.:SS ~9 ~^5^~CI533 FAX:No.:9 ~33?'X V 2. Contact:9X 5 *9"(L&i l (Xfi 3 ^5 Jeanette.I s b a q I e b &h RECEIVED JUN 14 201 » FRESNO COUNTYMENTALHEALTH COUNTY OF FRESNO Fresno,CA 32 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 PROVIDER:Linda Lose 2tllL kaigi7 Print Name:L~\Y\AC(l\\,Ln 5(c llf /l <j 01 pT Title:/,^0 a.Cl •'r<w>/i Date:O^OQ J I (0 AGREEMENT 15-247 AMENDMENT I Mailing Address: 1305 W.Bullard #11 Fresno,CA 93704 lioneNo.:(f 6$\*43%“3>0 <£\,A C 5Sn )(£&W ) AX:No.:(j5 CP)3/]2 -5 }LA Contact:L Dvia /V'l ,L 0 S6 .fftpt ,LfY\f T COUNTY OF FRESNO Fresno,CA 33 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 PROVIDER:Matthew Malta By;l/ZU^TXJ (C Print Name:l/V/V tX CAA*V ^i/\ Title:L-p-T Date:£|rS j (b Mailing Address: 264 Clovis Ave Ste 212 Clovis,VA 93612 Phone No.: FAX:No.: Contact: (4 <«i ) AGREEMENT 15-247 AMENDMENT I COUNTY OF FRESNO Fresno,CA -34- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: By pvvy yf /P h •£> Print Name: Title:/c ~h Date: Mailing Address: <r //nn /u -5 /*-/-/A /.S'S~ f^r^sn/n Csf 9 3 7/0 Phone No:(_g_z Z Fax No:(6~£rV)5 ?.T-/^^4 Contact:t J e tfA.r £>- COUNTY OF FRESNO Fresno ,CA -35- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: By .VS-t Print Name;4 '4 4 iSf Title:eHUdUL 44 Date:*1'5 "/fc 1 Mailing Address: Phone No:5~-Tf - Fax No:4 S ~D ~ST/ti Contact:/•ft/^17 ^ * COUNTY OF FRESNO •Fresno,CA 36 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Myrna Pacheco By :HMU /k\i\ "VtG <r( Print Name:^TVv?c (\ Title:GlM,V Date:(Q ~\S ~\^ Mailing Address: 5588 N.Palm Ave Fresno,CA 93704 Phone No.: FAX:No.:S S°\G Contact:”vGcWeCO \UA ^T w\ypc\cV\eco <g>Q -H".neG COUNTY OF FRESNO Fresno,CA 37 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Iris Person B y:kQsi A yO \4 r L .C S t U Print Name:S |^—C-£>CO Title:0 i <A \C Q-l Vvi QjfcK ..10 t S’f Date:(jj ''13"1 U? Mailing Address: 1600 Willow Avenue Clovis,CA 93612 Phone No.:£S FAX:No .:‘oS^f Contact:-JflS ^jTSO^ COUNTY OF FRESNO Fresno,CA -38- 1 2 3 4 5 6 8 9 10 11 12 13 14 15 16 17 13 19 20 21 22 23 24 25 26 6/7/16,3:30 PM to Message PowsoanEk.pdf 1 /1 PROVIDER:James Powroznik RECEIVED JUN 0 8 2016 FRESNO COUNTYMENTALHEALTH Print Name:lYtVtc-s fi P: Title:L/1fr- Date:khdlk ±%x AGREEMENT AMENDIV Mailing Address: 5588 N .Palm Ave Suite P4 Fresno,CA 93704 Phone No.:£,_oy /( FAX:No.:^-d 5tD-SST?oss^ Contact: Page 1 of 1 -39- t 1 1 3 l 5 6 $ 9 10 1 } 12 13 14 15 lb l ~ W i» r •• RECEIVED AUG 0 4 20 IB fRESNO feUH j VMENTALHEALTH 1PROVIDER;Cordie Micah Qualle 1B?M .*v I 22 2*•,t»iA ;•ft fYinc ,L&jAt jMjfA*.fibA^. fife Irfr DB&IH-H .MfeBg .&psss: at &*>^^ fkaneM»-«><*-^4t-16-1*1 *.***«*tgr^w s c s i-i f m'f i w £•. AC8a«PfflS4«I 4i®pspss.sprrj I cassraar *»JB»3 Ir.’^r w,r s 1 .'7 .28 40 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Kathryn Quinn-Crask V_-- \(/\y'l ft I A i r-T (-i7'Print Name: Title: Date: Mailing Address: 6215 N .Fresno Street,Suite 109 Fresno,CA 93710 Phone No.:O-Vf 7^Li°l FAX:No.:^c/£7 Contact: COUNTY OF FRESNO Fresno,CA 41 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15 -247 AMEND WENT I PROVIDER:Michelle Randolph By :. Print Name:}A \cX /\i (^V^wJ ^| L cst /J RECEIVED JUl .§i 20 if FRESVO COUAliYMENTALHEALT-j Title: Date:(_f )|)L? Mailing Address:4!>fr ^f 4 0 ,100 5070 N.Shcttrfrm-5 iOO K]-SlSt+K 4-(5~( Fresno,CA 93710 Phone No.:3>0^f _~>H FAX:No.:•"-S-'VV'^XA-P W\ACUr^Crfc SCA^Q £>bCQ(Obcd * Contact: fKbchfc- Michelle Randolph,LCSW 5100 N.Sixth St.#151.Fresno CA 93710 (559)304-3422 t 'O-P <=iJt COUNTY OF rRESNO Fi esno,CA 42 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 i 016 3 :50 PM FAX 3603854874 PRINTERY PROVIDER:Teresa Roltgen By: Print Name:Oxffi 3 Title:l ^h f l P T Date:fpjt^/i 6> ©0001 /0001 AGREEMENT 15-247 AMENDMENT 1 Mailing Address: 2505 W.Shaw Fresno,CA 93711 Phone No.:(55^)1^*5 7 FAX:NO.:£5<?J if 32 ~^5?? Contact: COUNTY OF FRESNO Fresno,CA -43- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Jorge Romero Print Name:A ' Title:LWFr Date:OjjMlMz Mailing Address: ASM £SHAW MA ffw° cA ^21io PI»»eNo:Z 7J & Fax No: Contact: COUNTY OF FRESNO Fresno,CA -44- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Laura Slagle By .V ^I t -IAA (T Print Name:L (XljJSOi }ft.13j I ^v 1 Title:L l\A PT Date:jCi3i I 112 Mailing Address: t/7 f \l ‘SiA -W-lo^ Phone No:(*S $°j\^1^7 ^~~^S'-?/ Fax No: Contact:L a.i/L-vry.H &C,I SAP COUNTY OF FRESNO Fresno,CA -45- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Dr.Denise D.Sniffin Tf Print NamdL E I S F ch&fot A-ft/(SvMiFRftJ j^.vb . Title:ULEKK^K (^l i Kf lPA (^.jf1 (^(rtfrigp Date:9 ILa U*- Mailing Address:um rt.\iUiu Alt FEBSWN Pfr Phone No: Fax No:dft %—\Q 'XO Contact:(\ilXfcil 4 t ^>A{}.lP/\kllf ) COUNTY OF FRESNO Fresno,CA -46- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER :Ronald Steele By Print Name: Title: Date: Mailing Address: y(XD H SOtSrfZ S7Z SiSz7£ 0&^%7/o Phone No: Fax No:2,0/8 Contact: COUNTY OF FRESNO Fresno,CA -47- 1 2 3-3 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PRO By y >JVlelissa Tihin Print Name:Mtyll ££47l1h )0 Title: Date: M mod i ^‘TkAapiSt' g/s/ltP Mailing Address: srif )Cfi 32£W . Phone No:2__ Fan No:fMmff }' Contact:Uf /ll ^\\C\ COUNTY or FRESNO Fresno,CA 48 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I 3y: Print Name:J /'UJlli 0 Title:k -OS k )&°l Hh ST Date: Mailing Address: 3097 Willow Ave Suite #8 Clovis,CA 93612 Phone No.: FAX No.: Contact: COUNTY OF FRESNO Fresno,CA -49- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: By . Print Name:Q (A\iV )rtf )±htf \jV| Title:UAfrT Date:"7 j j [\p Mailing Address: HI0 £•Shaw kJt \o3 Hrisno CA Phone No:f iiOlU Fax No:C S 24 -[\lQ°\ Contact:£\KU \feer COONTy OF FRESNO Fresno,CA 50 r: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 PROVIDER:Zoua Xiong unFrO Print Name:'Z-OVtl -j- Title: Date:^4 Mailing Address: 5588 N.Palm Avenue Fresno,CA 93704 Phone No.:XT?"'70e[~56 S / FAX:No.: Contact:TOMKrirfajtftPt ©gv&il-C0m- AGREEMENT 15-247 AMENDMENT I COUNTY OF FRESNO Fresno,CA 51 1 2 3 •; 5 6 7 8 9 1 0 11 12 13 14 15 16 17 18 19 2 0 2 1 2 2 2 3 2 4 2 5 2 6 27 2 8 AGREEMENT 15-247 AMENDMENT 1 PROVIDER ;Perry Young f N TBy:_'-H-:-j/uH i ^C ' *"7 • Print Name:C'y£V Title: Date: L MX '11 -j "'---j >‘TC 97c T J v -J?/-Vl 'M:> Mailing Address: 5707 N .Palm #103 Fresno,CA 93704 Phone No.: FAX:No.: Contact : COUNTY OF FRESNO Fresno.CA 52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Dr.Latif Ziyar By : Print Name: Title: Date:^T'"^b <I>S£Q1(&K r Mailing Address: 7335 N .F-irsf #T09 #1--Ut*Ji - &*s»ere7r9T7?0 fr<L~s^p ,J 3 7-^ Phone No.:(fS"<?J 4/V ?-? FAX :No.:^ Contact: COUNTY OF FRESNO Fresno,CA 53 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 PROVIDER: By: Asana Integrated Medical Group Print Name:Nitin Nanrla Title:CE0 Chairman of Board ,or President or any Vice President Date:8/4/16 _____ By: Print Name:Vik Marla Title:President and CFO Secretary (of Corporation),or any Assistant Secretary, Or Chief Financial Officer or any Assistant Treasurer Date:8/4/16 Mailing Address: 26135 Mureau Rd ,Suite 101 Calabasas CA 91302 AGREEMENT 15-247 AMENDMENT I Phone No.:,BlH .S~)51 Fax No.:OMilO Contact:RECEIVED MJG o 4 if!;.®!1 COUNTY OF FRESNO Fresno,CA -54- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RECEIVED JUL 0 8 2016 FRESNO COUNTYMENTALHEALTH PROVIDER:Bashful Elephant Counseling By . Print Name: Title: Date: L OfkfjL Mailing Address:ttklltoA Sull-e-£ dPtn/fS .&°j3J<J2s Phone No:31^^3^i Fax No: Contact:^/V£& AGREEMENT 15-247 AMENDMENT I COUNTY OF FRESNO Fresno,CA 55 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:BIO-BEHAVIORAL MEDICAL CLINICS,Inc. By: Print Name: Title: Date: Chairman of Board,or President or any Vice President"? T V UoruoA CTdrnQPrintName: rr\\y\Y ^Title: Secretary (of Corporation),or any Assistant Secretary, Or Chief Financial Officer or any Assistant Treasurer Date: :ial Otracer or any Assistant 1 reasur Mailing Address:QbQ Cl ) Phone Nd :c, Fax N(~S£PL)11 Contact:1V|Q^\I'lv L4T~C3 COUNTY OF FRESNO Fresno,CA 56 1 2 3 A 5 6 7 8 9 10 11 12 13 14 IS 16 17 18 19 20 21 22 23 24 25 26 27 28 @ 0002 /0007312:57 PM FAX i ' PROVIDER;Castani Family Services ! 3v:f &T *rint Namc^^^KUl /ai^-j_ rille:r)Ltif\SL\T ^I Chairman of Board ,or President or any Vice President 3ate:^/CJl ItiP ' Print Name: Title:jQjjnSJCL Secretary (of Corporation ),or any Assistant Secretary, Or Chief Financial Ofliceror any Assistant Treasurer Date:4/zZ/<71 Mailing Address:!• 51QQJSI kih jite*1&V PA 4?>-7 LO Phone No.:7.7 V 6/W Fax No.:JS.SS-ZW WO Contact: RECEIVED AUG 11 to® AGREEMENT 15-247 AMENDMENT I i 1 -COtJNTY OF FRESNO I’tenn.C'A 57 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 PROVIDER:DN Associates6V—' Print Name: Title: Chairman of Board,or President or any Vice President Date:^3 By: Print Name: Title: Secretary (of Corporation),or any Assistant Secretary, Or Chief Financial Officer or any Assistant Treasurer Date: Mailing Address: T>j ^spc^ATe ^qatgo to.AJ& r^too , Phone No.:5~T-^~ Fax No.:«<3^7 ^.*7 Contact:u &.Ti S ’PorJ&JA AJ AGREEMENT 15-247 AMENDMENT I -I -COUNTY OF FRESNO Fresno,CA 58 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Dunamis,Inc By:£ Print Name:fo .’UQAH jJ_ Title: Date: By: f -airman of Board,or President or any Vice President C -te -/<£> Print Name:<£Hdc*(Se -X^rA-es Title:.SeafjflaiitjjSecretary(of Corporation),or any Assistant Secretary,or Chief Financial Officer or any Assistant Treasurer Date:CsJA -lA Mailing Address: 4991 E.McKinley #112 Fresno,CA 93727 Phone No.: FAX:No.: Contact: COUNTY OF FRESNO Fresno,CA 59 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Fresno American Indian Health Project Print Name: Title:C-VtipL fTtofm OfifW. :irman of BcS^d ,or President or any Vice President Date: A-'Print Name:' Secretary (of Corporation),or any AssistantJ^ecretary,or Chief 1 isur is Title Assistant Treasurer Chief Financial Officer or any Date: Mailing Address: 1551 E.Shaw Ave #139 Fresno,CA 93710 Phone No.:55*?-3<S-0 0WO FAX:No.:657-3^0 ~0 Contact: COUNTY OF FRESNO Fresno,CA -60- 1 2 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: Generational Changes,Inc. Print Name:T.inria Washington ,CFO Title:CEO Date: Mailing Address: 2409 Merced Street #106 Fresno ,Ca 93721 Phone No:559 981 2795 Fax No:559 981 6925 Contact:Anita Washington ,office Manager COUNTY OF FRESNO Fresno,CA 61 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER: By; Print Name: Title: Chairman of Board,or President or any Vice President Date:£?i3>/i By: Print Name: Title: Secretary (of Corporation),or any Assistant Secretary, Or Chief Financial Officer or any Assistant Treasurer Date: Mailing Address: (K lA-V-.\O 6^^n i O Phone No.:^^^^ Fax No.: Contact:K}O pAtX-A—; l COUNTY OF FRESNO Fresno,CA 62 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER :Kids Play Therapy,Inc. c Print Name: Title: mam U )rrtts (LAO Chairman of Board,or President or any Vice President Date:(f ^j By:^7 ] Print Name:^QjLti£L(A[ b.rCt i C.Z .O -Title: Secretary (of Corporation),or any Assistant Secretary,or Chief Financial Officer or any Assistant Treasurer Date: Mailing Address: 5100 N.Sixth #140 Fresno,CA 93710 Phone No. FAX:No. Contact: : ~o :S -AAl -'UI <-[Lj COUNTY OF FRESNO -63- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RECEIVED AUG 9 9 2016 FRESNO COUNTYPROVIDER:La Familia Therapy Services MENTAL HEALTH By Print Name:(/,c fo r ,A ZlZ&-^ Title:Z //d Date:j - Mailing Address: /f f o r //7 /o s??' 7J9 J?/,<)crsi c/-f /r?r /$-tf g Phone No:S5°1 Q ‘T Fax No:SSLSU 335 '5 ~7 ^3 Contact:(///r'/)"r //j^£j_f )i^f ~U /-(A yr' AGREEMENT 15-247 AMENDMENT I COUNTY OF FRESNO Fresno,CA 64 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Marjaree Mason Center By:. Print Name Kumj# Title:TNgOdlV6 ImJSr:Chairman of Board ,or President or any Vice President Date:(0 (\11/7 By: Print Name:O']c^>r 1 i 5>^0 gj.C^f \ Title:Q Secretary (of Corporation),or any Assistant Secretary,or Chief Financial Officer or any Assistant Treasurer Date:Cp /13/(G? Mailing Address: 1600 M Street Fresno,CA 93721 Phone No.:•2^1.<-/Q(p FAX:No.:55 ^-237-<3 ^20 Contact: COUNTY OF FRESNO Fresno,CA 65 1 2 3 4 5 6 n 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:NirmaS S.Brar,MD By:./ Print Name:Aft nrA ]&Id 4m Title: Date: By: ArfSi dm f Chairman of Board,or President or any Vice President O'?//< Print Name: Title: Secretary (of Corporation),or any Assistant Secretary,or Chief Financial Officer or any Assistant Treasurer Date: Mailing Address: 1130 E.Shaw Ste 105 Fresno,CA 93710 Phone No.: FAX:No.: Contact: COUNTY OF FRESNO Fresno,CA 66 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 RECEIVED AUG 1 8 2016 FRESNO COUNTYMENTALHEALTH PROVIDER ;ORCHID INTERPRETING Print Name:1— Title:t'WvA olf Chairman of Board,or President or any Vice President Dale: By. Title:CZF &f Secretary (of Corporation),or any Assistant Secretary, Or Chief Financial Officer or any Assistant Treasurer Date:PAJIAJJA Mailing Address: .J>!viz OldVi#lA Phone No.: Fax.No.: Contact: ,555-StdO S37?-<7 LW -i - AGREEMENT 15-247 AMENDMENT 1 COUNTY OF PRT-SNO Fresno,CA 67 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Sullivan Center for Children By:/IS t Print Name:Ijl PV HfVfO Title:Aki^i 4 Chairman of Board,or Presit Date: Chairman of Board,or President or any Vice President Print Name: Title: Secretary (of Corporation)7br any Assistant Secretary, Or Chief Financial Officer or any Assistant Treasurer Date: Mailing Address: M ShMO Phone No.:fsS*?!1 -/ISIfi Fax No-:(S-gS )37 l -XHI Contact: COUNTY OF FRESNO Fresno,CA 68 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 AGREEMENT 15-247 AMENDMENT I PROVIDER:Vasquez Clinical Services Print Name: Title:cit'd to**nan o/Board ,oivrrc l (b Chairman of Board ,i Date:S 'Y'YC* resident or any Vice President By: Print Name: Title: Secretary (of Corporation ),or any Assistant Secretary, Or Chief Financial Officer or any Assistant Treasurer Date:. Mailing Address; =r/6-LJs SLMJ-iSilh: as C^L Phone No.:f Fax No,: Contact ;.£b4 tlv gC-b COUNTY or FRF.SNOFresno,CA Page 1 of 2 Revised Exhibit A Individual Providers Name Address Al-Saoudi,Yuleen 516 Villa Suite #3 Clovis,CA 93612 Amato,Dolores G.6777 N.Willow Avenue Fresno,CA 93710 Amling-Heiken,Jane 5464 N.Palm #B Fresno,CA 93704 Armer,Justin 4721 W.Jennifer Avenue #2 Fresno,CA 93722 Avina,Erica 614 N Street Sanger,CA 93657 Bergstrom,Virginia 5588 N.Palm Ave Fresno,CA 93704 Brookins,Antionette 3723 E.Dakota Fresno,CA 93711 Burkes-Bell,Dianne 2652 E.Fallbrook Avenue Fresno,CA 93720 Cabrera,Hector 614 N Street Sanger,CA 93657 Casas,Judith M.4946 E.Yale Ave.#101,Fresno,CA 93727 Case,Gabriele 1451 W.Shaw Avenue Fresno,CA 93711 Casillas,Jennell A.770 E.Shaw Ave.,Suite 103 Fresno,CA 93710 Cerda,Claudia 6777 N.Willow Avenue Fresno,CA 93710 Constant,Andrew 3869 Alamos Avenue Clovis,CA 93619 De Leon,Cynthia 516 Villa St #3 Clovis,CA 93612 Dickey,Judith 5707 N.Palm #103 Fresno,CA 93704 Farris,Donald K .3740 Circle Dr.Fresno,CA 93704-4765 Garvey,Catherine 5475 N.Fresno Street #101 Fresno,CA 93710 Glidden,Howard,Dr.1660 E.Herndon #150 Fresno,CA 93720 Hayden,Kathy 2715 N.Thorne Avenue Fresno,CA 93704 Jackson-Salcedo,Peggy,Dr.1575 N.Van Ness Fresno,CA 93728 Johnson,David 3097 Willow Ave Suite #3 Clovis,CA 93612 King,Frances 3114 Willow Ave Ste 102 Clovis,CA 93612 Lopez,Jeanette 2008 N.Fine #103 Fresno,CA 93727 Lose,Linda 1305 W.Bullard #11 Fresno,CA 93704 Malin,Matthew 264 Clovis Ave Ste 212 Clovis,CA 93612 Mar,Jeffrey 5100 N.Sixth Street #151 Fresno,CA 93710 McIntosh,Wanda K.Gordon P.O.Box 27826 Fresno,CA 93729 Pacheco,Myrna 5588 N.Palm Ave Fresno,CA 93704 Person,Iris 1600 Willow Avenue Clovis,CA 93612 Powroznik,James 5588 N.Palm Ave Suite P4 Fresno,CA 93704 Qualle,Cordie Micah 264 Clovis Ave Ste 212 Clovis,CA 93612 Quinn-Crask,Kathryn 6215 N.Fresno #109 Fresno,CA 93710 Randolph,Michelle 5100 N.Sixth Street #151 Fresno,CA 93710 Roltgen,Teresa 2505 W.Shaw Fresno,CA 93711 Romero,Jorge 438 E.Shaw Avenue #140 Fresno,CA 93710 Slagle,Laura 6276 N.First Street #103 Fresno,CA 93710 Sniffin,Denise D.6777 N.Willow Avenue Fresno,CA 93710 Steele,Ronald 5150 N.Sixth Street #129 Fresno,CA 93710 Page 2 of 2 Revised Exhibit A Tihin,Melissa 770 E.Shaw Ave.#103 Fresno,CA 93710 Trujillo,Erlinda 3097 Willow Avenue Suite 8 Clovis,CA 93612 Walker,Samantha 770 E.Shaw Ave.,Suite 103 Fresno,CA 93710 Xiong,Zoua 5588 N.Palm Avenue Fresno,CA 93704 Young,Perry 5707 N.Palm #103 Fresno,CA 93704 Ziyar,Latif,Dr.1702 E.Utah Avenue Fresno,CA 93720 Group Providers Name Address Asana Integrated Medical Group 5016 Chesebro Road,Ste 200 Agora Hills,CA 91301 Bashful Elephant Counseling 3097 Willow Ave Suite #4 Clovis,CA 93612 Bio-Behavioral Medical Clinics,Inc.1060 W.Sierra,Suite 105 Fresno,CA 93711 Castani Family Services 5700 N 6th Street Suite 104 Fresno,CA 93710 DN Associates 4991 E.McKinley #112 Fresno,CA 93711 Dunamis,Inc 4991 E McKinley #112 Fresno,CA 93727 Fresno American Indian Health Project 1551 E.Shaw Ave.#139,Fresno,CA 93710 Generational Changes,Inc.2409 Merced Ste 106 Fresno,CA 93721 House Psychiatric Clinic,Inc.1322 E.Shaw Ave Suite 410 Fresno,CA 93710 Kids Play Therapy,Inc.5100 N.Sixth #140 Fresno,CA 93710 La Familia Therapy Services 7281 N.Sandrini Avenue Fresno,CA 93722 Marjaree Mason Center 1600 M Street Fresno,CA 93721 Nirmal S.Brar,MD 1130 E.Shaw Ste 105 Fresno,CA 93710 Orchid Interpreting 1602 E.Divisadero Street,Fresno CA 93721 Sullivan Center for Children 3443 W.Shaw Ave Fresno,CA 93711 Vasquez Clinical Services 516 W.Shaw Ave,Suite 200 Fresno,CA 93704 Exhibit C Page 1 of 3 FRESNO COUNTY MENTAL HEALTH COMPLIANCE PROGRAM CONTRACTOR CODE OF CONDUCT AND ETHICS Fresno County is firmly committed to full compliance with all applicable laws, regulations,rules and guidelines that apply to the provision and payment of mental health services. Mental health contractors and the manner in which they conduct themselves are a vital part of this commitment. Fresno County has established this Contractor Code of Conduct and Ethics with which contractor and its employees and subcontractors shall comply.Contractor shall require its employees and subcontractors to attend a compliance training that will be provided by Fresno County.After completion of this training,each contractor,contractor’s employee and subcontractor must sign the Contractor Acknowledgment and Agreement form and return this form to the Compliance officer or designee. Contractor and its employees and subcontractor shall: 1.Comply with all applicable laws,regulations,rules or guidelines when providing and billing for mental health services. 2.Conduct themselves honestly,fairly,courteously and with a high degree of integrity in their professional dealing related to their contract with the County and avoid any conduct that could reasonably be expected to reflect adversely upon the integrity of the County. 3.Treat County employees,consumers,and other mental health contractors fairly and with respect. 4.NOT engage in any activity in violation of the County’s Compliance Program,nor engage in any other conduct which violates any applicable law,regulation,rule or guideline 5.Take precautions to ensure that claims are prepared and submitted accurately,timely and are consistent with all applicable laws,regulations,rules or guidelines. 6.Ensure that no false,fraudulent,inaccurate or fictitious claims for payment or reimbursement of any kind are submitted. 7.Bill only for eligible services actually rendered and fully documented.Use billing codes that accurately describe the services provided. Exhibit C Page 2 of 3 8.Act promptly to investigate and correct problems if errors in claims or billing are discovered. 9.Promptly report to the Compliance Officer any suspected violation(s)of this Code of Conduct and Ethics by County employees or other mental health contractors,or report any activity that they believe may violate the standards of the Compliance Program,or any other applicable law,regulation,rule or guideline.Fresno County prohibits retaliation against any person making a report.Any person engaging in any form of retaliation will be subject to disciplinary or other appropriate action by the County.Contractor may report anonymously. 10.Consult with the Compliance Officer if you have any questions or are uncertain of any Compliance Program standard or any other applicable law,regulation,rule or guideline. 11 .Immediately notify the Compliance Officer if they become or may become an Ineligible person and therefore excluded from participation in the Federal Health Care Programs. Exhibit C Page 3 of 3 Fresno County Mental Health Compliance Program Contractor Acknowledgment and Agreement I hereby acknowledge that I have received,read and understand the Contractor Code of Conduct and Ethics.I herby acknowledge that I have received training and information on the Fresno County Mental Health Compliance Program and understand the contents thereof.I further agree to abide by the Contractor Code of Conduct and Ethics,and all Compliance Program requirements as they apply to my responsibilities as a mental health contractor for Fresno County. I understand and accept my responsibilities under this Agreement.I further understand that any violation of the Contractor Code of Conduct and Ethics or the Compliance Program is a violation of County policy and may also be a violation of applicable laws,regulations,rules or guidelines.I further understand that violation of the Contractor Code of Conduct and Ethics or the Compliance Program may result in termination of my agreement with Fresno County.I further understand that Fresno County will report me to the appropriate Federal or State agency. For Individual Providers Name (print): Discipline:Psychiatrist Psychologist LCSW LMFT Signature :Date : For Group or Organizational Providers Group/Org.Name (print): Employee Name (print): Discipline:Psychiatrist Psychologist LCSW LMFT I I Other: Job Title (if different from Discipline): Signature:Date:// Exhibit D Page 1 of 3 Documentation Standards For Client Records The documentation standards are described below under key topics related to client care.All standards must be addressed in the client record;however,there is no requirement that the record have a specific document or section addressing these topics. A .Assessments 1.The following areas will be included as appropriate as a part of a comprehensive client record. •Relevant physical health conditions reported by the client will be prominently identified and updated as appropriate. •Presenting problems and relevant conditions affecting the client’s physical health and mental health status will be documented ,for example:living situation,daily activities, and social support. •Documentation will describe client’s strengths in achieving client plan goals. •Special status situations that present a risk to clients or others will be prominently documented and updated as appropriate. •Documentations will include medications that have been described by mental health plan physicians,dosage of each medication,dates of initial prescriptions and refills,and documentations of informed consent for medications. •Client self report of allergies and adverse reactions to medications,or lack of known allergies/sensitivities will be clearly documented. •A mental health history will be documented,including:previous treatment dates, providers,therapeutic interventions and responses,sources of clinical data,relevant family information and relevant results of relevant lab tests and consultations reports. •For children and adolescents,pre-natal and perinatal events and complete developmental history will be documented. •Documentations will include past and present use of tobacco,alcohol,and caffeine,as well as illicit,prescribed and over-the-counter drugs. •A relevant mental status examination will be documented. •A five axis diagnosis from the most current DSM,or a diagnosis from the most current ICD,will be documented,consistent with the presenting problems,history mental status evaluation and/or other assessment data. 2.Timeliness/Frequency Standard for Assessment •An assessment will be completed at intake and updated as needed to document changes in the client’s condition. •Client conditions will be assessed at least annually and,in most cases,at more frequent intervals. Exhibit D Page 2 of 3 B.Client Plans 1 .Client plans will: •have specific observable and/or specific quantifiable goals•identify the proposed type(s)of intervention •have a proposed duration of intervention(s) •be signed (or electronic equivalent)by: *the person providing the service(s),or *a person representing a team or program providing services,or a person representing the MHP providing services when the client plan is used to establish that the services are provided under the direction of an approved category of staff,and if the below staff are not the approved category, a physician *a licensed /“waivered”psychologist a licensed/“associate”social worker *a licensed/registered/marriage and family therapist or *a registered nurse •In addition, client plans will be consistent with the diagnosis,and the focus of intervention will be consistent with the client plan goals,and there will be documentation of the client’s participation in and agreement with the plan.Examples of the documentation include, but are not limited to,reference to the client’s participation and agreement in the body of the plan,client signature on the plan,or a description of the client’s participation and agreement in progress notes. *client signature on the plan will be used as the means by which the CONTRACTOR(S)documents the participation of the client when the client’s signature is required on the client plan and the client refuses or is unavailable for signature,the client plan will include a written explanation of the refusal or unavailability. The CONTRACTOR(S)will give a copy of the client plan to the client on request. 2.Timeliness/Frequency of Client Plan: •Will be updated at least annually •The CONTRACTOR(S)will establish standards for timeliness and frequency for the individual elements of the client plan described in item 1. C.Progress Notes 1.Items that must be contained in the client record related to the client’s progress in treatment include: •The client record will provide timely documentation of relevant aspects of client care •Mental health staff/practitioners will use client records to document client encounters, including relevant clinical decisions and interventions Exhibit D Page 3 of 3 •All entries in the client record will include the signature of the person providing the service (or electronic equivalent);the person’s professional degree,licensure or job title; and the relevant identification number,if applicable •All entries will include the date services were provided •The record will be legible •The client record will document follow-up care,or as appropriate,a discharge summary 2.Timeliness/Frequency of Progress Notes: Progress notes shall be documented at the frequency by type of service indicated below: A.Every Service Contact Mental Health Services•Medication Support Services•Crisis Intervention Exhibit E Page 1 of 2 STATE MENTAL HEALTH REQUIREMENTS 1.CONTROL REQUIREMENTS The COUNTY and its subcontractors shall provide services in accordance with all applicable Federal and State statutes and regulations. 2.PROFESSIONAL LICENSURE All (professional level )persons employed by the COUNTY Mental Health Program (directly or through contract)providing Short-Doyle/Medi-Cal services have met applicable professional licensure requirements pursuant to Business and Professions and Welfare and Institutions Codes. 3.CONFIDENTIALITY CONTRACTOR shall conform to and COUNTY shall monitor compliance with all State of California and Federal statutes and regulations regarding confidentiality,including but not limited to confidentiality of information requirements at 42,Code of Federal Regulations sections 2.1 et seq;California Welfare and Institutions Code,sections 14100.2,11977,11812,5328;Division 10.5 and 10.6 of the California Health and Safety Code;Title 22,California Code of Regulations,section 51009;and Division 1,Part 2.6,Chapters 1-7 of the California Civil Code. 4.NON-DISCRIMINATION A.Eligibility for Services CONTRACTOR shall prepare and make available to COUNTY and to the public all eligibility requirements to participate in the program plan set forth in the Agreement.No person shall,because of ethnic group identification,age,gender,color,disability,medical condition,national origin,race,ancestry,marital status,religion,religious creed,political belief or sexual preference be excluded from participation,be denied benefits of,or be subject to discrimination under any program or activity receiving Federal or State of California assistance. B.Employment Opportunity CONTRACTOR shall comply with COUNTY policy,and the Equal Employment Opportunity Commission guidelines,which forbids discrimination against any person on the grounds of race,color,national origin,sex,religion,age,disability status,or sexual preference in employment practices.Such practices include retirement,recruitment advertising,hiring,layoff,termination,upgrading,demotion,transfer, Exhibit E Page 2 of 2 rates of pay or other forms of compensation,use of facilities,and other terms and conditions of employment. C.Suspension of Compensation If an allegation of discrimination occurs,COUNTY may withhold all further funds,until CONTRACTOR can show clear and convincing evidence to the satisfaction of COUNTY that funds provided under this Agreement were not used in connection with the alleged discrimination. D.Nepotism Except by consent of COUNTY’S Department of Behavioral Health Director,or designee,no person shall be employed by CONTRACTOR who is related by blood or marriage to,or who is a member of the Board of Directors or an officer of CONTRACTOR. 5.PATIENTS'RIGHTS CONTRACTOR shall comply with applicable laws and regulations,including but not limited to,laws,regulations,and State policies relating to patients'rights Revised Exhibit F Page 1 of 2 Medi-Cal Provider Standards 1.The Medi-Cal Provider possesses the necessary license to operate,if applicable,and any required certification. 2.The space owned ,leased or operated by the Provider and used for services or staff meets local fire codes. 3.The physical plant of any site owned,leased,or operated by the Provider and used for services or staff is clean,sanitary and in good repair. 4.The Medi-Cal Provider maintains client records in a manner that meets applicable state and federal standards. 5.The Medi-Cal Provider has staffing adequate to allow the County to claim federal financial participation for the services the Provider delivers to beneficiaries,as described in Division 1,Chapter 11,Subchapter 4 of Title 9,CCR,when applicable. 6.The Medi-Cal Provider that provides or stores medications,the Provider stores and dispenses medications in compliance with all pertinent state and federal standards.In particular: A.All drugs obtained by prescription are labeled in compliance with federal and state laws.Prescription labels are altered only by persons legally authorized to do so. B.Drugs intended for external use only or food stuffs are stored separately from drugs for internal use. C.All drugs are stored at proper temperatures,room temperature drugs at 59-86 degrees F and refrigerated drugs at 36-46 degrees F. D.Drugs are stored in a locked area with access limited to those medical personnel authorized to prescribe,dispense or administer medication. E.Drugs are not retained after the expiration date.IM multi-dose vials are dated and initialed when opened. F.A drug log is maintained to ensure the Provider disposes of expired , contaminated,deteriorated and abandoned drugs in a manner consistent with state and federal laws. G.Policies and procedures are in place for dispensing,administering and storing medications. Revised Exhibit F Page 2 of 2 7.The Medi-Cal Provider that provides day treatment intensive or day rehabilitation,the Provider must have a written description of the day treatment intensive and/or day treatment rehabilitation program that complies with State Department of Health Care Services’day treatment requirements.The COUNTY shall review the Provider’s written program description for compliance with the State Department of Health Care Services’ day treatment requirements. 8.The COUNTY may accept the host county’s site certification and reserves the right to conduct an on-site certification review at least every three (3)years.The COUNTY may also conduct additional certification reviews when: A.The Provider makes major staffing changes. B.The Provider makes organizational and/or corporate structure changes (example: conversion from a non-profit status). C.The Provider adds day treatment or medication support services when medications shall be administered or dispensed from the Provider site. D.There are significant changes in the physical plant of the Provider site (some physical plant changes could require a new fire clearance). E.There is change of ownership or location. F.There are complaints against the Provider. G.There are unusual events,accidents,or injuries requiring medical treatment for clients,staff or members of the community. Revised Exhibit G Page 1 of 2 Fresno County Mental Health Plan Grievances and Appeals Process The Fresno County Mental Health Plan (MHP)provides beneficiaries with a grievance and appeal process and an expedited appeal process to resolve grievances and disputes at the earliest and the lowest possible level. Title 9 of the California Code of Regulations requires that the MHP and its fee-for-service providers to give verbal and written information to Medi-Cal beneficiaries regarding the following: •How to access specialty mental health services•How to file a grievance about services•How to file for a State Fair Hearing The MHP has developed a Consumer Guide,a beneficiary rights poster,a grievance form,an appeal form,and Request for Change of Provider Form.All of these beneficiary materials must be posted in prominent locations where Medi-Cal beneficiaries receive outpatient specialty mental health services,including the waiting rooms of providers’offices of service. Beneficiaries have the right to use the grievance and/or appeal process without any penalty,change in mental health services,or any form of retaliation.All Medi-Cal beneficiaries can file an appeal or state hearing. Grievances and appeals forms and self-addressed envelopes must be available for beneficiaries to pick up at all provider sites without having to make a verbal or written request.Forms can be sent to the following address: Fresno County Mental Health Plan P.O.Box 45003 Fresno,CA 93718-9886 (800)654-3937 (for more information) (TTY)Dial 771 to reach the California Relay Service Provider Problem Resolution and Appeals Process The MHP uses a simple,informal procedure in identifying and resolving providerconcernsandproblemsregardingpaymentauthorizationissues,other complaints and concerns. Informal provider problem resolution process -the provider may first speak to a Provider Relations Specialist (PRS)regarding his or her complaint or concern. Revised Exhibit G Page 2 of 2 The PRS will attempt to settle the complaint or concern with the provider.If the attempt is unsuccessful and the provider chooses to forego the informal grievance process,the provider will be advised to file a written complaint to the MHP address (listed above). Formal provider appeal process -the provider has the right to access the provider appeal process at any time before,during,or after the provider problem resolution process has begun,when the complaint concerns a denied or modified request for MHP payment authorization,or the process or payment of a provider’s claim to the MHP. Payment authorization issues -the provider may appeal a denied or modified request for payment authorization or a dispute with the MHP regarding the processing or payment of a provider’s claim to the MHP.The written appeal must be submitted to the MHP within ninety (90)calendar days of the date of the receipt of the non-approval of payment. The MHP shall have sixty (60)calendar days from its receipt of the appeal to inform the provider in writing of the decision,including a statement of the reasons for the decision that addresses each issue raised by the provider,and any action required by the provider to implement the decision. If the appeal concerns a denial or modification of payment authorization request,the MHP utilizes Managed Care staff who were not involved in the initial denial or modification decision to determine the appeal decision. If the Managed Care staff reverses the appealed decision,the provider will be asked to submit a revised request for payment within thirty (30)calendar days of receipt of the decision Other complaints -if there are other issues or complaints,which are not related to payment authorization issues,providers are encouraged to send a letter of complaint to the MHP.The provider will receive a written response from the MHP within sixty (60) calendar days of receipt of the complaint.The decision rendered by the MHP is final. FRESNO COUNTY MENTAL HEALTH PLAN INCIDENT REPORTING Revised Exhibit H Page 1 of 2 PROTOCOL FOR COMPLETION OF INCIDENT REPORT •The Incident Report must be completed for all incidents involving clients.The staff person who becomes aware of the incident completes this form,and the supervisor co-signs it. •When more than one client is involved in an incident,a separate form must be completed for each client. Where the forms should be sent -within 24 hours from the time of the incident •Incident Report should be sent to: Managed Care Division Manager Fresno County Mental Health Plan P.O.Box 45003 Fresno,CA 93718-9886 Revised Exhibit H Page 2 of 2 INCIDENT REPORT WORKSHEET When did this happen?(date/time)Where did this happen? Name/DMH # 1.Background information of the incident: 2.Method of investigation:(chart review,face-to-face interview,etc.) Who was affected?(If other than consumer) List key people involved,(witnesses,visitors,physicians,employees) 3.Preliminary findings:How did it happen?Sequence of events.Be specific.If attachments are needed write comments on an 8 1/2 sheet of paper and attach to worksheet. Outcome severity:Nonexistent |inconsequential |consequential j "f death j j not applicable jj unknown 4.Response:a)corrective action,b)Plan of Action,c)other Completed by (print name) Completed by (signature)Date completed Reviewed by Supervisor (print name) Supervisor Signature Date Exhibit K Page 1 of 2 SELF-DEAUNG TRANSACTION DISCLOSURE FORM In order to conduct business with the County of Fresno (hereinafter referred to as "County"), members of a contractor's board of directors (hereinafter referred to as "County Contractor"),must disclose any self-dealing transactions that they are a party to while providing goods,performing services,or both for the County.A self-dealing transaction is defined below: "A self-dealing transaction means a transaction to which the corporation is a party and in which one or more of its directors has a material financial interest" The definition above will be utilized for purposes of completing this disclosure form. INSTRUCTIONS (1)Enter board member's name,job title (if applicable),and date this disclosure is being made. (2)Enter the board member's company/agency name and address. (3)Describe in detail the nature of the self-dealing transaction that is being disclosed to the County.At a minimum,include a description of the following: a.The name of the agency/company with which the corporation has the transaction;and b.The nature of the material financial interest in the Corporation's transaction that the board member has. (4)Describe in detail why the self-dealing transaction is appropriate based on applicable provisions of the Corporations Code. (5 )Form must be signed by the board member that is involved in the self-dealing transaction described in Sections (3)and (4). Exhibit K Page 2 of 2 {1}Company Board Member Information: Name:Date: Job Title: (2)Company/Agency Name and Address: {3)Disclosure (Please describe the nature of the self -dealing transaction you are a party to) (4)Explain why this self -dealing transaction is consistent with the requirements of Corporations Code 5233 (a ) (5)Authorized Signature Date:Signature: