HomeMy WebLinkAboutAgreement A-23-252 Amendment I to Agreement with TCMG.pdf Agreement No. 23-252
1 AMENDMENT NO. 1 TO AGREEMENT
2 THIS AMENDMENT, hereinafter referred to as Amendment No. 1, is made and entered into
3 this 6th day of June 2023, by and between the COUNTY OF FRESNO, a
4 Political Subdivision of the State of California, hereinafter referred to as "COUNTY," and Total Care
5 Medical Group, a California Corporation, whose address is 5361 E. Kings Canyon Road, Fresno, CA
6 93727, hereinafter referred to as "CONTRACTOR."
7 WITNESSETH:
8 WHEREAS, the parties entered into that certain Agreement, identified as COUNTY Agreement
9 No. A-19-187, effective April 23, 2019, hereinafter referred to collectively as COUNTY's Agreement No.
10 A-19-187, for medical incapacity evaluation assessment services and professional services for
11 COUNTY's Departments of Social Services (DSS); and
12 WHEREAS, the parties desire to amend the Agreement regarding changes as stated below and
13 extend the term of this contract.
14 NOW, THEREFORE, in consideration of their mutual promises, covenants and conditions,
15 hereinafter set forth, the sufficiency of which is acknowledged, the parties agree as follows:
16 1. That the existing COUNTY Agreement No. A-19-187, Page two (2), Section three (3)
17 beginning with Line seven (7), with the number "3" and ending on Page two (2), Line thirteen (13)with
18 the word "performance", be deleted and the following inserted in its place:
19 "3. TERM
20 This Agreement shall be effective on the 1st day of May 2019 through and including June
21 30, 2024.
22 2. That the existing COUNTY Agreement No. A-19-187, Page three (3), Section five (5)
23 beginning with Line eight (8), with the number "S' and ending on Page four (4), Line ten (10) with the
24 word "received", be deleted and the following inserted in its place:
25 "4. COMPENSATION/INVOICING
26 County agrees to pay CONTRACTOR and CONTRACTOR agrees to receive compensation as
27 follows: Ninety-Five and No/100 Dollars ($95.00) for each medical assessment. COUNTY's DSS shall
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I pay for Glycohemoglobin tests when necessary to effectively evaluate an applicant's employability at the
2 rate of Forty-Eight and 50/100 Dollars ($48.50) per Glycohemoglobin test. COUNTY's DSS shall pay for
3 other diagnostic tests when necessary to effectively evaluate an applicant's employability at the rate of
4 Fifty and No/100 Dollars ($50.00) per diagnostic test. COUNTY's DSS shall pay for interpreter services
5 at the rate of One Hundred and No/100 Dollars ($100.00) per assessment, when necessary. In no event
6 shall compensation for actual services performed be in excess of One Hundred and Five Thousand and
7 No/100 Dollars ($105,000.00) for the initial fourteen (14) month period during which this Agreement is in
8 effect, and in no event shall compensation for actual services performed be in excess of Ninety
9 Thousand and No/100 Dollars ($90,000.00) for the subsequent (12) month periods during which this
10 Agreement is in effect. The cumulative total of this Agreement shall not be in excess of Four Hundred
11 and Sixty-Five Thousand and No/100 Dollars ($465,000.00). It is understood that all expenses incidental
12 to CONTRACTOR's performance of services under this Agreement shall be borne by CONTRACTOR.
13 CONTRACTOR shall invoice COUNTY in arrears by the tenth (10th) day of each month for
actual expenses incurred and services rendered in the previous month to:
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DSSlnvoices@FresnoCountyCA.gov. A monthly activity report shall accompany the invoice, reflecting
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services supported by the invoiced expenditures and be in a form and in such detail as acceptable to
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COUNTY's DSS. No reimbursement for services shall be made until invoices, reports and outcomes are
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received, reviewed and approved by COUNTY's DSS.
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At the discretion of COUNTY's DSS Director or designee, if an invoice is incorrect or is otherwise
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not in proper form or substance, COUNTY's DSS Director or designee shall have the right to withhold
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payment as to only that portion of the invoice that is incorrect or improper after five (5) days prior notice
21 to CONTRACTOR. CONTRACTOR agrees to continue to provide services for a period of ninety (90)
22 days after notification of an incorrect or improper invoice. If after the ninety (90) day period, the
23 invoice(s) is still not corrected to COUNTY's DSS satisfaction, COUNTY's DSS Director or designee
24 may elect to terminate this Agreement, pursuant to the termination provisions stated in Section Four (4)
25 of this Agreement. In addition, for invoices received ninety (90) days after the expiration of each term of
26 this Agreement or termination of this Agreement, at the discretion of COUNTY's DSS Director or
2 V designee, COUNTY's DSS shall have the right to deny payment of any additional invoices received.
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1 3. That all references in existing COUNTY Agreement No. A-19-187 to Exhibit A shall be
2 changed to read "Revised Exhibit A," where appropriate, which is attached hereto and incorporated
3 herein by this reference.
4 4. The parties agree that this Amendment may be executed by electronic signature as
5 provided in this section.
6 a) An "electronic signature" means any symbol or process intended by an individual
7 signing this Amendment No. 3 to represent their signature, including but not limited to
8 (1) a digital signature; (2) a faxed version of an original handwritten signature; or (3)
9 an electronically scanned and transmitted (for example by PDF document) of a
10 handwritten signature.
11 b) Each electronic signature affixed or attached to this Amendment No. 3 (1) is deemed
12 equivalent to a valid original handwritten signature of the person signing this
13 Amendment No. 3 for all purposes, including but not limited to evidentiary proof in any
14 administrative or judicial proceeding, and (2) has the same force and effect as the
valid original handwritten signature of that person.
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c) The provisions of this section satisfy the requirements of Civil Code section 1633.5,
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subdivision (b), in the Uniform Electronic Transaction Act (Civil Code, Division 3, Part
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2, Title 2.5, beginning with Section 1633.1).
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d) Each party using a digital signature represents that it has undertaken and satisfied
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the requirements of Government Code section 16.5, subdivision (a), paragraphs (1)
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through (5), and agree that each other party may rely upon that representation.
21 e) This Amendment No. 3 is not conditioned upon the parties conducting the
22 transactions under it by electronic means and either party may sign this Agreement
23 with an original handwritten signature.
24 5. COUNTY and CONTRACTOR agree that this Amendment No. 1 is sufficient to amend
25 Agreement No. A-19-187 and, that upon execution of this Amendment No. 1, the original Agreement
26 and this Amendment No. 1, shall together be considered the Agreement.
27 The Agreement, as hereby amended, is ratified and continued. All provisions, terms, covenants,
28 conditions and promises contained in this Agreement not amended herein shall remain in full force and
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I effect. This Amendment No. 1 shall become effective upon execution on the day first written
2 hereinabove.
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1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment I to Agreement No.
2 A-19-187 as of the day and year first hereinabove written.
3 ATTEST:
4 CONTRACTOR: COUNTY OF FRESNO
Total Care Medic
5
6 By:
S Q in ero, hairman of the Board of
Sultyelvisors of the County of Fresno
S Print Name:
9 ���►�
Title:
i
10 Chairman of the Board, or
President, or any Vice President
11 ATTEST:
BERNICE E. SEIDEL, Clerk
12 Clerk of the Board of Supervisors
13 County of Fresno, State of California
19
By: _
15 Deputy
16
17 Mailing Address:
18 5361 E. Kings Canyon Rd., Ste. 101
19 Fresno, CA 93727
Phone No.: (559) 251-2225
20
21
FOR ACCOUNTING USE ONLY:
22 Fund/Subclass: 0001/10000
23 Organization: 6645
Account: 7870
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SB:jv
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Revised Exhibit A
Page 1 of 7
Summary of Services: General Relief Medical Evaluations
ORGANIZATION: Total Care Medical Group
ADDRESS: 5361 E. Kings Canyon Rd., Ste. 101
Fresno, CA, 93727
TELEPHONE: 559-251-2225, ext. 107
FAX: 559-251-9575
CONTACT: Kelsie Emerzian
EMAIL: kelsie(a)totalcaremg.com
CONTRACT PERIOD: May 1, 2019 through June 30, 2020 - $105,000
July 1, 2020 through June 30, 2021 - $90,000 (optional)
July 1, 2021 through June 30, 2022 - $90,000 (optional)
July 1, 2022 through June 30, 2023 - $90,000 (optional)
July 1, 2023 through June 30, 2024 - $90,000 (optional)
CONTRACT AMOUNT:
Not to exceed $465,000
SUMMARY OF SERVICES
Total Care Medical Group (CONTRACTOR) will provide medical services, including physical
exams and related diagnostic tests, to adults referred for evaluation of ability to be gainfully
employed.
I. CONTRACTOR SHALL PROVIDE THE FOLLOWING SERVICES FOR DSS:
A. CONTRACTOR will provide professional services, including physical exams and
related diagnostic tests for the purposes of determining the person's ability to be
gainfully employed.
B. CONTRACTOR will accept a maximum of five (5) referrals per service day, or
equivalent, for physical exams and related diagnostic tests.
C. Designate a physician to provide the services under this Agreement, who shall
perform services in accordance with appropriate scientific, professional, and ethical
standards of the medical profession. At all times they shall act within the policies,
rules and regulations of the County of Fresno, the California State Department of
Health, state and local statutes, and administrative regulations relating to health
services. In the absence of the designated physician, CONTRACTOR agrees to
provide an alternate physician, Physician's Assistant (PA) or Family Nurse
Practitioner (FNP) to perform all services as described under this Agreement. The
names of physician, PA and/or FNP providing services are to be given to DSS at the
commencement of the Agreement. In the event there are staffing changes,
CONTRACTOR will inform DSS in writing within seven days.
D. CONTRACTOR will complete the GR8085 form (Revised Exhibit A pages 4 - 5)
during each physical exam, and return all completed forms to DSS within one week.
The GR8085
Revised Exhibit A
Page 2 of 7
form may be updated from time to time, and CONTRACTOR is required to use the
most recent version as provided by COUNTY.
E. A copy of the GR8085 form (Revised Exhibit A pages 4 - 5) is to be released to
DSS only if applicant gives authorization to CONTRACTOR by signing a copy of
the Authorization for Access, Use, and Disclosure of Protected Health Information
(Exhibit A pages 6 - 7). CONTRACTOR should receive a copy of the signed release
from the client when they arrive for their appointment. Should a client refuse to sign
the authorization form, they must be informed that they may still have their
Verification of Incapacity form completed, but will be required to return the form to
DSS independently. The Authorization for Access, Use, and Disclosure of Protected
Health Information form may be updated from time to time, and CONTRACTOR is
required to use the most recent version as provided by COUNTY.
F. If CONTRACTOR suspects that an applicant may have mental health issues,
CONTRACTOR will document finding on the GR8085 form. CONTRACTOR agrees
to refer these persons to the appropriate mental health evaluation service as
designated by DSS.
G. CONTRACTOR will provide the completed GR8085 forms to designated DSS staff
via email utilizing 128-Bit Advanced Encryption Standard on a weekly basis.
H. CONTRACTOR will provide copies of the medical appointment calendar to DSS no
later than the 15th of the month prior to the calendar month.
I. CONTRACTOR shall ensure that interpreting and translation services are provided
to persons with limited English proficiency. Interpreting services must be provided
in-house at no charge when available, or through certified interpreting services when
CONTRACTOR's employees are unable to provide interpreting.
J. Designate CONTRACTOR staff who will work closely with DSS staff to provide
assistance as required for fulfilling the terms of this Agreement.
K. CONTRACTOR will meet with DSS staff at a minimum quarterly or as often as
needed, for service coordination, problem/issue resolution, information sharing, and
review and monitoring of project services and fiscal reports.
II. DSS SHALL BE RESPONSIBLE FOR THE FOLLOWING:
A. DSS will refer persons applying for General Relief to CONTRACTOR for physical
exams and related diagnostic tests in order to determine their incapacity to be
gainfully employed.
B. DSS will provide persons applying for General Relief with a copy of the GR8085 form
and the Authorization for Access, Use, and Disclosure of Protected Health
Information form to take to their scheduled physical exam with CONTRACTOR.
C. DSS will request applicants, on a voluntary basis, complete and sign an
Authorization for Access, Use, and Disclosure of Protected Health Information form
before scheduled physical exam in order for CONTRACTOR to release the GR8085
form to DSS staff.
Revised Exhibit A
Page 3 of 7
D. Designate a DSS staff member to receive GR8085 forms via email utilizing 128-Bit
Advanced Encryption Standard on a weekly basis.
E. Designate DSS staff who will work closely with CONTRACTOR to provide assistance
as required for fulfilling the terms of this Agreement.
F. Meet with CONTRACTOR staff at a minimum quarterly or often as needed for
service coordination, problem/issue resolution, information sharing, and review and
monitoring of project services and fiscal reports.
G. DSS will notify CONTRACTOR of any non-English speaking applicants before their
scheduled appointment in order for CONTRACTOR to secure appropriate
interpreting services.
III. FEES FOR SERVICES
Fees for services provided under this Agreement shall be as follows:
■ Examinations: $95.00 each.
■ Glycohemoglobin tests: $48.50 each.
■ Other diagnostic tests: $50.00 each.
■ Interpreter services: $100.00 each.
Interpreter services may only be billed for outside interpreting services, and only for
languages other than Spanish, Hmong, Lao, and Vietnamese. Spanish, Hmong, Lao,
and Vietnamese interpreting shall be provided by Total Care Medical Group's in-
house staff at no charge. However, exceptions may be made when in-house staff is
not available to provide interpreting in these languages at the time of the
appointment.
co
O 1856 O
FRESH Revised Exhibit A
Paqe 4 of 7
Department of Social-Services
Verification of Incapacity Case No.:
Case Name:
SSN:
Date:
Worker No.:
The following information is needed to determine your eligibility for General Relief.
Please return this form by:
Medical release authorization: I authorize my medical provider to release the following information:
Patient or Representative Signature Date
Health Care Provider: Please answer the questions below.
1. Does the patient have a physical or mental health condition that prevents or substantially reduces
their ability to engage in work or training?
❑ No (please answer question 9 and sign the form)
❑ Yes (please answer the following questions:
2. Onset date:
3. Expected ❑ Temporary, expect to release patient for work on:
duration:
❑ Permanent
4. Are they able to work? ❑ No, please go to no. 5 ❑ Yes, please answer the following questions:
Can perform ❑ limited full-time work ❑ limited part-time work
5. Describe how the physical and mental condition reduces their ability to engage in work:
6. Is the physical or mental condition primarily due to drug and/or alcohol abuse?
❑ Yes ❑ No ❑ Unknown
7. Has the patient submitted a disability insurance application for completion?
❑ Yes ❑ No ❑ Unknown
If yes, date submitted:
GR8085 09-19-17 FileNET: Case Verification
Revised Exhibit
CO A Page 5 of 7
Department of Social Services
p� 1856 p
FRESH Verification of Incapacity
Case No.:
Case Name:
SSN:
Date:
Worker No.:
8. Is the patient receiving or seeking ❑ Yes ❑ No ❑ Unknown
treatment?
9. 1 recommend a referral for: ❑ Mental Condition
❑ Physical Condition
❑ None
Comments:
Signature of Health Care Provider Date
Print Name
Title
Agency
Address
Phone No.
DEA No.
GR8085 09-19-17 FileNET: Case Verification
Revised Exhibit
COtI A Page 6of7
t County of Fresno
RETURN TO TABLE OF CONTENTS
AUTHORIZATION FOR ACCESS, USE, AND DISCLOSURE OF PROTECTED
HEALTH INFORMATION
Name: Date of Birth:
Last 4 Digits of Social Security Number: Record#
Access, Use, and Disclosure of Health Information
authorize the access, use, or disclosure of the above named individual's health
information, which may contain medical, mental health, or substance abuse history and
treatment information, as follows:
Name of the organization or individual authorized to access, use, or disclose the
information (information to be released from):
Address:
Name of the organization or individual authorized to receive and use the information
(information to be released to):
Address:
The type and amount of information to be accessed, used, or disclosed is as follows:
❑ Diagnosis ❑ Lab Report ❑ Immunization Record
❑ History & Physical ❑ Medication Record ❑ Progress Note
❑ Assessment ❑ Plan of Care ❑ Other
Dates of information from: to:
Exception or information I do not want disclosed:
This information will be used for the following purpose:
❑ Coordination/Continuity of Care ❑ Legal ❑ Insurance
0 Eligibility for Public Assistance ❑ Social Security Appeal
❑ Disability Claim ❑ Other
Restrictions
California law does not allow the organization or individual receiving this information to
access, use, or make further disclosure of my protected health information unless the
organization or individual obtains another authorization from me or unless access, use,
and disclosure is specifically required or permitted by law.
2910: Attachment A Revised Exhibit A
Page 7 of 7
Authorization for Access, Use, and
Rights Disclosure of Protected Health Information
understand that I have the following rights with respect to this Authorization:
1 . 1 may refuse to sign this authorization.
2. 1 have a right to receive a copy of this authorization.
3. 1 may revoke this Authorization at any time by signing the revocation at the bottom
of this form or by a written notice of revocation signed by me or on my behalf. I can
mail it or personally deliver to the following address:
understand that the revocation will be effective upon receipt. I understand that the
revocation will not apply to information that has already been released in response
to this authorization.
4. 1 may not be required to sign this Authorization as a condition to obtaining
treatment, payment, or my eligibility for benefits.
5. 1 am entitled to notice if Fresno County will access, use, or disclose the protected
health information for marketing and receive payment for the access, use, or
disclosure of my protected health information.
6. 1 understand that I may request a restriction or limitation on the protected health
information to be accessed, used, or disclosed.
7. 1 understand that information disclosed pursuant to this authorization may be
subject to redisclosure by the recipient and may no longer be protected by
confidentiality laws including the Health Insurance Portability and Accountability Act
(H I PAA).
Expiration
This Authorization will expire on: If I do not specify an
expiration date or event, this authorization will expire in one year.
Signature
knowingly and voluntarily sign this authorization:
Signature Date
Printed Name Telephone Number
Address
If signed by someone other than client/consumer, state your legal relationship to
the client/consumer:
Witness/Language Interpreter
❑ I revoke this authorization Signature: Date