HomeMy WebLinkAboutAgreement A-09-022-3 with Psychological Institute Inc..pdf Agreement No.09-022-3
1 AMENDMENT III TO AGREEMENT
2 This AMENDMENT, hereinafter referred to as Amendment III, is made and entered into this
3 o-"A day of ��, p , 2015, by and between the COUNTY OF FRESNO, a Political
4 Subdivision of the State of California, hereinafter referred to as "COUNTY", and CALIFORNIA
5 PSYCHOLOGICAL INSTITUTE, INC., a For Profit Corporation, whose address is 1470 W.
6 Herndon Avenue, Suite#300, Fresno, California 93711, hereinafter referred to as "PROVIDER"
7 (collectively the "parties").
8 WHEREAS, the parties entered into that certain Agreement, identified as COUNTY Agreement
9 No. 09-022, effective January 1, 2009, and Amendment I (A-09-022-1), effective July 1, 2010, and
10 Amendment 11 (A-09-022-2), effective June 30, 2011, hereinafter collectively referred to as COUNTY
11 Agreement No. 09-022, whereby PROVIDER agreed to provide outpatient specialty mental health
12 services to certain Fresno County Medi-Cal beneficiaries, as part of the Mental Health Plan (MHP)
13 submitted to the California State Department of Health Care Services (DHCS) pursuant to Article 5,
14 section 14680-14685, Chapter 8.8, Division 9,Welfare and Institutions Code, and originally approved
15 by the Fresno County Board of Supervisors on March 17, 1998 and updated from time to time; and
16 WHEREAS, the parties desire to amend COUNTY Agreement No. 09-022, as stated below and
17 restate the Agreement in its entirety.
18 NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of which is
19 hereby acknowledged,the parties agree as follows:
20 1. That the existing COUNTY Agreement No. 09-022, Page Sixteen(16), Section 4.3, Line
21 Seventeen (17), beginning with the number "4.3.1" and ending on Page Seventeen(17), Line Twelve
22 (12) with the word "Agreement" be deleted and the following inserted in its place:
23 "4.3.1 Reimbursement
24 Revised Exhibit C-2, which is attached hereto and incorporated herein, shall be the
25 basis for reimbursement to PROVIDER for rendering Covered Services to Members, at the prevailing
26 fee-for-service reimbursement rates of payment for provider services, identified in Revised Exhibit D-2
27 "Provider Fee Schedule", which is attached hereto and incorporated herein, at the time such specialty
28 mental health services are rendered. If Members have other health insurance coverage, PROVIDER
COUNTY OF FRESNO
Fresno, CA
1 must bill any such third party coverage for the Covered Services provided, and COUNTY shall have no
2 obligation to make any payment to PROVIDER. Where applicable, PROVIDER shall submit claims to
3 COUNTY along with a copy of third-party payer denial letter or explanation of benefits (EOB) within
4 thirty (30) days of the date of such denial letter or EOB.
5 PROVIDER agrees to limit administrative cost to a maximum of fifteen percent
6 (15%) of the total program budget and to limit employee benefits to a maximum of twenty percent
7 (20%) of total salaries for those employees working under this Agreement during the term of this
8 Agreement. Failure to conform to this provision will be grounds for contract termination at the option
9 of the COUNTY.
10 In no event shall services provided by PROVIDER during the term of this
11 Agreement exceed:
12 1) One Million, Five Hundred Thousand, One and No/100 Dollars
13 ($1,500,001.00) for the period of January 1, 2009 through June 30, 2009; and
14 2) Three Million, Ninety Thousand, One and No/100 Dollars ($3,090,001.00)
15 for the period of July 1, 2009 through June 30, 2010; and
16 3) Three Million, One Hundred Eighty-Two Thousand, Seven Hundred One
17 and No/100 Dollars ($3,182,701.00) for the period of July 1, 2010 through June 30, 2011; and
18 4) Three Million, One Hundred Fourteen Thousand, Two Hundred Seventy-
19 Three and No/100 Dollars ($3,114,273.00) for the period of July 1, 2011 through June 30, 2012; and
20 5) Three Million, Two Hundred Seven Thousand, Six Hundred Ninety-Nine
21 and No/100 Dollars ($3,207,699.00) for the period of July 1, 2012 through June 30, 2013; and
22 6) Three Million, Two Hundred Seven Thousand, Seven Hundred One and
23 No/100 Dollars ($3,207,701.00), for the period of July 1, 2013 through June 30, 2014; and
24 7) Three Million, Six Hundred Thousand, and No/100 Dollars
25 ($3,600,000.00) for the period of July 1, 2014 through June 30, 2015; and
26 8) Three Million, Two Hundred Seven Thousand, Seven Hundred One and
27 No/100 Dollars ($3,207,701.00), for the period of July 1, 2015 through June 30, 2016.
28
- 2 -
COUNTY OF FRESNO
Fresno, CA
I In no event shall services provided by PROVIDER for the period January 1, 2009
2 through June 30, 2016 pursuant to this Agreement exceed Twenty-Four Million, One Hundred Ten
3 Thousand, Seventy-Seven and No/100 Dollars($24,110,077.00), during the term of this Agreement."
4 2. That the existing COUNTY Agreement No. 09-022, Page Eighteen(18), Section Five (5),
5 beginning on Line Fifteen (15) with the number"5.1" and ending on line Twenty-One (21), with the
6 word"term" be deleted and the following inserted in its place:
7 "5.1 Term
8 This Agreement shall become effective on the I"day of January 2009 and shall
9 terminate on the 30'h day of June 2009.
10 This Agreement shall automatically be extended for seven (7) additional twelve
11 (12)month periods upon the same terms and conditions herein set forth, unless written notice of non-
12 renewal is given by PROVIDER, or COUNTY, or COUNTY's Department of Behavioral Health
13 Director, or designee, not later than ninety (90) days prior to the close of the current Agreement term."
14 3. That the existing COUNTY Agreement No. 09-022, Page Twenty (20), Section Five (5),
15 beginning on Line Twelve (12) with the number"5.3.1" and ending on line Twenty (20), with the
16 word"herein"be deleted and the following inserted in its place:
17 "5.1.3 Modification by Mutual Agreement
18 Any matters of this Agreement may be modified from time to time by the written
19 consent of all parties without, in any way, affecting the remainder.
20 Notwithstanding the above, changes to line items in the budget, as set forth in
21 Revised Exhibit C-2, that do not exceed ten percent(10%)of the maximum compensation payable to
22 the PROVIDER, and changes to the service volume/types of service units to be provided as set forth in
23 Revised Exhibit C-2, may be made with the written approval of COUNTY's DBH Director, or
24 designee. Said budget line item and service volume/types of service units changes shall not result in
25 any change to the maximum compensation amount payable to PROVIDER, as stated herein."
26 4. That in the existing COUNTY Agreement No. 09-022, the following is inserted on page
27 Twenty-Four (24), Line Nineteen (19), as part of Section 7.0:
28
3 -
COUNTY OF FRESNO
Fresno, CA
1 "E. Sexual Abuse/Molestation Liability
2 Sexual Abuse/Molestation Liability Insurance (including but not limited to
3 corporal punishment liability, sexual abuse and molestation liability, and child
abduction liability) with limits of not less than One Million Dollars ($1,000,000)
4 per occurrence, Two Million Dollars ($2,000,000) annual aggregate. This policy
shall be issued on a per occurrence basis."
5
6 5. That in the existing COUNTY Agreement No. 09-022, the following is inserted on page
7 Thirty-Four(34), right after Section 9.14 (Disclosure of Self-Dealing Transactions), as Sections 9.15
8 and 9.16:
9 "9.15 Disclosure of Ownership and/or Control Interest Information
10 This provision is only applicable if PROVIDER is a disclosing entity, fiscal agent,
11 or managed care entity as defined in Code of Federal Regulations (C.F.R), Title 42 § 45 5.101
12 455.104, and 455.106(a)(1),(2).
13 In accordance with C.F.R., Title 42 §§ 455.101, 455.104, 455.105 and
14 455.106(a)(1),(2), the following information must be disclosed by PROVIDER by completing Exhibit
15 H, "Disclosure of Ownership and Control Interest Statement", attached hereto and by this reference
16 incorporated herein and made part of this Agreement. PROVIDER shall submit this form to
17 COUNTY's DBH within thirty (30) days of the effective date of this Agreement. Additionally,
18 PROVIDER shall report any changes to this information within thirty-five (35) days of occurrence by
19 completing Exhibit H, "Disclosure of Ownership and Control Interest Statement." Submissions shall
20 be scanned PDF copies and are to be sent via email to DBHAdministration@co.fresno.ca.us attention:
21 Contracts Administration.
22 9.16 Disclosure - Criminal History and Civil Actions
23 PROVIDER is required to disclose if any of the following conditions apply to
24 them, their owners, officers, corporate managers and partners (hereinafter collectively referred to as
25 "PROVIDER"):
26 A. Within the three-year period preceding the Agreement award, they have
27 been convicted of, or had a civil judgment rendered against them for:
28
4 -
COUNTY OF FRESNO
Fresno, CA
1 1. Fraud or a criminal offense in connection with obtaining,
2 attempting to obtain, or performing a public (federal, state, or
3 local) transaction or contract under a public transaction;
4 2. Violation of a federal or state antitrust statute;
5 3. Embezzlement, theft, forgery, bribery, falsification, or destruction
6 of records; or
7 4. False statements or receipt of stolen property.
8 B. Within a three-year period preceding their Agreement award, they have
9 had a public transaction(federal, state, or local)terminated for cause or default.
10 Disclosure of the above information will not automatically eliminate
11 PROVIDER from further business consideration. The information will be considered as part of the
12 determination of whether to continue and/or renew the contract and any additional information or
13 explanation that PROVIDER elects to submit with the disclosed information will be considered. If
14 it is later determined that the PROVIDER failed to disclose required information, any contract
15 awarded to such PROVIDER may be immediately voided and terminated for material failure to
16 comply with the terms and conditions of the award.
17 PROVIDER must sign a"Certification Regarding Debarment, Suspension,
18 and Other Responsibility Matters- Primary Covered Transactions" in the form set forth in Exhibit I,
19 attached hereto and by this reference incorporated herein. Additionally, PROVIDER must
20 immediately advise the County in writing if, during the term of this Agreement: (1) PROVIDER
21 becomes suspended, debarred, excluded or ineligible for participation in federal or state funded
22 programs or from receiving federal funds as listed in the excluded parties' list system
23 (http://www.sam.gov); or(2) any of the above listed conditions become applicable to PROVIDER.
24 PROVIDER shall indemnify, defend and hold the COUNTY harmless for any loss or damage
25 resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed
26 Certification Regarding Debarment, Suspension, and Other Responsibility Matters."
27 6. That the existing COUNTY Agreement No. 09-022, Sections 9.15 (Non-Exclusive
28 Contracts)through 9.19 (Entire Agreement) be renumbered to read Sections 9.17 through 9.21.
- 5 -
COUNTY OF FRESNO
Fresno, CA
1 7. That all references in existing COUNTY Agreement No. 09-022, as previously amended,
2 to "Revised Exhibit C-1" and"Revised Exhibit D-1" shall be changed to read "Revised Exhibit C-2"
3 and"Revised Exhibit D-2" where appropriate, each attached hereto and incorporated herein by
4 reference.
5 8. That all references in existing COUNTY Agreement No. 09-022, as previously amended,
6 to the name "California Department of Mental Health(DMH)" shall be changed to read"California
7 Department of Health Care Services (DHCS)", where appropriate.
8 9. That Exhibit G is deleted in its entirety.
9 10. COUNTY and PROVIDER agree that this Amendment III is sufficient to amend
10 Agreement No. 09-022. Amendment I, Amendment 11 and this Amendment III together shall be
11 considered the Agreement. The Agreement, as hereby amended, is ratified and continued. All
12 provisions, terms, covenants, conditions and promises contained in the Agreement, and not amended
13 herein, shall remain in full force and effect. This Amendment III shall become effective on July 1,
14 2014.
15
16
17
18
19 ///
20
21
22
23
24
25
26
27
28
- 6 -
COUNTY OF FRESNO
Fresno, CA
IN WITNESS WHEREOF, the parties hereto have executed this Amendment III to Agreement as
of the day and year first hereinabove written.
PROVIDER: COUNTY OF FRESNO
CALIFORNIA PSYCHOLOGICAL
INSTITUTE, INC.
By By
r Chairman, Board of Supervisors
Print �,1,� �I il�gC� i
Title: �� Date: y
Chairman of the Board, or
President, or any Vice President
BERNICE E. SEIDEL, Clerk
Board of Supervisors
By iz By
Print Name:
Title: Date: 015
Secretary (of Corpo ion), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
Mailing Address:
1470 W. Herndon Avenue, Suite 300 PLEASE SEE ADDITIONAL
Fresno, CA 93711 SIGNATURE PAGE ATTACHED
Phone No.: (559) 256-2000
Contact: Michelle Owhadi, Administrative Director
7 -
COUNTY OF FRESNO
Fresno, CA
I APPROVED AS TO LEGAL FORM:
2 DANIEL C. CEDERBORG, COUNTY COUNSEL
3
By
4
5 APP OVED AS TO ACCOUNTIN :
VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
6 TREASURER-TAX COLLECTOR
7
8 By
9 REVIEWED AND RECOMMENDED FOR APPROVAL:
10
11 By
12 Dawan Utecht, Direct r
13 Department of Behavioral Health
14 REVIEWED AND RECOMMENDED FOR APPROVAL:
15
By
16 Delfino E. Neira, Director
17 Department of Social Services
18
Fund/Subclass: 0001/10000
19 Organizations: 56302666
20 Accounts/Programs: 7223/0
21 Fund/Subclass: 0001/10000
22 Organizations: 56107001 (Non-medical billable services for DSS consumers only)
Accounts/Programs: 7870/0
23
Fiscal Year Maximums:
24 l/l/2009—6/30/2009: $1,500,001
25 FY 2009-10: $3,090,001
FY 2010-11: $3,182,701
26 FY 2011-12: $3,114,273
FY 2012-13: $3,207,699
27 FY 2013-14: $3,207,701
28 FY 2014-15: $3,600,000
FY 2015-16: $3,207,701
- 8 -
COUNTY OF FRESNO
Fresno, CA
Revised Exhibit C-2
California Psychological Institute
Budget Period -July 1, 2014 to June 30, 2015
Page 1 of 4
Bud et Categories- Total Proposed Budget
Line Item Description(Must be itemized) FTE% Admin. Direct Total
PERSONNEL SALARIES:
0001 Clinical Director 1.00 $65,000 $60,000 $125,000
0002 i Psychiatrist) 0.60 $145,600 $145,600
0003 !Clinicians( Intems) _ 8.00 $428,480 $428,480
0004 CIinica,ns Licensed 6.00 $480,000 $480,000
0005 (Case Manp9erers 10.00 $377,000 $377,000
0006 Admin/Support Staff 10.00 $686,400 $686,400
$0
SALARY TOTAL 35.60 $751,400 $1,491,0801 $2,242,480
PAYROLL TAXES:
0030. OAS-DI - $130,007
0031 FICA/MEDICARE $30,405
0032 U.I. $10,217
PAYROLL TAX TOTAL $0 $0 $170,629
EMPLOYEE BENEFITS:
0040 Retirement $60,000
0041 Workers Compensation $10,500
0042 Health Insurance(medical vision, life, dental) $200,000
EMPLOYEE BENEFITS TOTAL $0 $0 $270,500
SALARY&BENEFITS GRAND TOTAL; $2,683,609
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $266,075
loll Rent/Lease Equipment $4,000
1012 Utilities _ $27,000
1013 Janitorial $31,620
1014 !Common Area Maint. $10,000
1015 Maintenance(facility)- $10,000
FACILITY/EQUIPMENT TOTAL $348,695
OPERATING EXPENSES:
1060 Telephone $17,425
1061 Answerin Service/Schedules $3 600
1062 -- Postage - _ _- $2,200
1063 Printing/Reproduction/Advertising + 7 $3,000
1064 (Publications -_ _ - $360
1065 Leal $3,500
1066 Office Supplies&Equipment $25,000
1067 :Household Supplies ! $9,500
+ - - -
1068 !Food $10,000
1069 _!Program Supplies $15,000
1070 Program Supplies-Psych Testing - _- _._._ $3 700
1071 -!Transportation of Clients- - - -- -- - - --- $2,500
1672 Staff Mileage/vehicle maintenance I $61,993
Revised Exhibit C-2
Page 2 of 4
1073 Staff Training/Registration _- _ $10,000
1074 Administrative Overhead $61,421
OPERATING EXPENSES TOTAL $229,199
FINANCIAL SERVICES EXPENSES:
1080 lAccountinaMookkeeping -_ - $25,055
1081 Liability Insurance $28,986
1082 :Payroll Processing $23,000
FINANCIAL SERVICES TOTAL $77,041
SPECIAL EXPENSES (Consultant/Etc.):
1083 Consultant(network&data management) $60,000
— -T- — - - -- - -
1084 Translation Services _— $1,000
1085 Electronic Health Record $20,000
1086 1 Incentive Program $122,456
!SPECIAL EXPENSES TOTAL ! $203,456
FIXED ASSETS:
2000 - Computers&Software $48,000
2001 'Furniture&Fixtures -- -...-- - - i---- -- $10,000
2003 Other $0
FIXED ASSETS TOTAL $58,000
- - - -
TOTAL PROGRAM EXPENSES 3,600,000
PROJECTED REVENUE: Volume Rate $Amount
3000 'Mental Health Services 1,051,314 $2.61 $2,743,931
(Assessment Plan of Care,Individua&FamW)Group Therapy,Rehab) $0
3100 Case Management, Linkage/Brokerage 168,513 $2.02 $340,396
3200 Crisis Intervention 310 $3.88 $1,203
3300 iMedication Support 43,000 $4.82 $207,260
3400 Collateral 37,000 $2.61 $96,570
3500 Court Documentation, Report,Appearance 900 $60.00 $54,000
3600 Psychological evaluation/Bonding Study 43,246 $3.61 $156,118
3700 ICC 200 $2.61 $522
3800 _ _ IHBS - - - _ 0 --- ---- -
- - --. --- - - $2.61 - - $0
3900 other 0 $0.00 $0
TOTAL PROJECTED REVENIJEJ 1,344,7831 $3,600,000
- '- - - - -- _ -- _- 'Medi-cal Revenue --- - -� - -
- �- - - - -
$1,8001000
Cost Per Unit 2.677608146
Revised Exhibit C-2
California Psychological Institute
Budget Period -July 1,2015 to June 30,2016
Page 3 of 4
Budget Categories__ Total Proposed Budget
Line Item Description(Must be itemized) F T E % Admin. Direct Total
PERSONNEL SALARIES:
0001 Clinical Director 1.00 $122,500 $122,500
0002 Psychiatrist 0.60 $145,600 $145,600
0003 Clinicians(Interns) 8.00 $428,480 $428,480
I- n
-- -- ) -- - - -- . -- --
0004 Clinicians(Licensed) 6.00 $420,700 $420,700
0005___ Case Managers 10.00 $377,000 $377,000
0006 lAdmin/Support Staff 10.00 $599,000 $599,000
SALARY TOTAL 35.60 $599,000 $1,494,280 $2,093,280
PAYROLL TAXES:
0030 jOASDI - _ - $120,756
0031 FICA/MEDICARE $28,241
0032 1U.I. $10,218
;PAYROLL TAX TOTAL $0 $0 $159,215
EMPLOYEE BENEFITS:
0040 Retirement - $59,000
0041 I Workers Compensation $10,500
0042 Health Insurance(medical,vision, life, dental) $190,000
EMPLOYEE BENEFITS TOTAL 1 $0 $0 $259,500
SALARY&BENEFITS GRAND TOTAL( $2,511,995
FACILITIES/EQUIPMENT EXPENSES:
1010 Rent/Lease Building $266,075
1011 _Rent/Lease Equipment- $20,000
1012 Utilities $27,000
1013 'Janitorial -+ $31,620
1014 Maintenance(facility) $15,000
FACILITY/EQUIPMENT TOTAL $359,695
OPERATING EXPENSES:
1060 (Telephone $10,000
1061 Answering Service $3,600
1062 Postage _ $2,200
---- -
1063 Printing/ReproductioNAdvertising 3,000
-_......_ ---. $ ..
1064 Publications
- --
360
1065 Le al $3,500
1066 (Office Supplies&Equipment _ - I - $30,000
1067 !Household SWplies
----------
1068 'Food $12,000
1069 11 Pro�c ram Supplies . - - -- - -- -- - -- - $10,300
-- - - -
1070 Pogram Supplies-Ps�rch Testier - - -- - --- --- - t- _ _ $3,700
1071 Transportation of Clients $2,000
Revised Exhibit C-2
Page 4 of 4
1072 Staff mileage/vehicle maintenance -_ _ $45,000
1073 I Staff Training/Re isg tration $10,000
1074 Administrative Overhead $13,990
.OPERATING EXPENSES TOTAL $159,150
FINANCIAL SERVICES EXPENSES:
1080 _jAccountin /Bookkeepinq 1 $9,500
1081 Liability Insurance _-- - - _ -__ I - ._—__. .._. $28,986
1082 Payroll Processing $30,000
FINANCIAL SERVICES TOTAL $68,486
SPECIAL EXPENSES (Consultant/Etc.)
1083 Consultant(network&data management) j $28,000
1084 Translation Services _ $1,000
1085 Electronic Health Record $20,000
1086 Incentive Program $50,375
SPECIAL EXPENSES TOTAL $99,375
FIXED ASSETS:
2000 Computers&Software 1 $4,500
2001 Furniture& Fixtures $4,500
2002 Other $0
'FIXED ASSETS TOTAL $9,000
TOTAL PROGRAM EXPENSES $3,207,701
PROJECTED REVENUE: Volume Rate $Amount
3000 iMental Health Services 465,945 $2.61 $1,216,116
i(Assessment,Plan of Care,IndividuaWamilyrGroup Therapy, Rehab):!
3100 Case Management, Linkage/Brokerage 240,040 $2.02 $484,881
3200 Crisis Intervention 600 $3.88 $2,328
3300 Medication Support 149,920 $4.82 $722,614
Youth Link&Other Services
3400 1 Collateral 125,000 $2.61 $326,250
- - -- ------ -- . . .. -
3500 Court Documentation, Report Appearance 2,000 $60.00 $120,000
3600 Psycholo ical evaluation 62,400 $3.61 $225,264
3700 ICC_ 4 2,0 00 $2.61- $109,620
3800 _ IHBS - 240— $2.61 $626
3900 'other 0 $0.00 $0
TOTAL PROJECTED REVENUE 1,088,145 $3,207,701
_-- _ Cost Per Unit 1 $3
Projected Cost Settlement Due County or Due Contractor $0
Revised Exhibit D-2
PROVIDER FEE SCHEDULE
July 1, 2015 through June 30, 2016
CALIFORNIA PSYCHOLOGICAL INSTITUTE
Avatar
Service Description Service Code Per Min.
Mental Health Services:
Individual Assessment: Non-MD X9504M 3 $ 2.61
Individual or Family Therapy: MD X9601M 3 $2.61
Individual or Family Therapy: Non-MD X9600M 3 $ 2.61
Group Therapy: Non-MD X9506M 82 $2.61
Group Rehabilitative X9505M 85 $2.61
Collateral: Non-MD X9546M 150 $2.61
Rehabilitation X9055M 158 $ 2.61
Plan Development X9054M 159 $ 2.61
Test Administration: Non-MD X9516M 891 $ 2.61
ICC 205 $2.61
IHBS 127 $2.61
Case Management Services:
Case Management: Linkage, Consultation, Placement X9205M 205 $ 2.02
Crisis Services:
Crisis Intervention ED: MD 99283M 31 $ 3.88
Crisis Intervention ED: Non-MD X9031 M 31 $3.88
Medication Support Services:
Meds Interview: MD 90862M 42 $4.82
Services for Court Referred Cases
Psychologist
Psychological Evaluation 1(480 mins. or 8 hrs. max.) X9504M 96 $3.61
Psychological Evaluation 11 (600 mins. or 10 hrs. max.) X9504M 96 $3.61
All Disciplines
Bonding Study I or 11 (600 mins. or 10 hrs. max) X9504M 97 $ 2.61
Family Psychodynamic Formulation(600 mins. or 10 X9504M 98 $ 2.61
hrs. max)
Attachment Assessment(600 mins. or 10 hrs. max) X9504M 99 $ 2.61
Court Report(per report) CR 3CR $ 60.00/report
Court Testimony(per hour of testimony, Court prep or CT 3CT $ 60.00/report
wait time)
Exhibit H
Page 1 of 2
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. Identifying Information
Name of entity DIBIA
Address(number,street) City State ZIP code
CLIA number Taxpayer ID number(EIN) Telephone number
( )
II. Answer the following questions by checking "Yes" or "No." If any of the questions are answered "Yes," list names and
addresses of individuals or corporations under"Remarks" on page 2. Identify each item number to be continued.
YES NO
A. Are there any individuals or organizations having a direct or indirect ownership or control interest
of five percent or more in the institution, organizations, or agency that have been convicted of a criminal
offense related to the involvement of such persons or organizations in any of the programs established
by Titles XVIII,XIX, or XX?......................................................................................................................... 0 0
B. Are there any directors, officers, agents, or managing employees of the institution, agency, or
organization who have ever been convicted of a criminal offense related to their involvement in such
programs established by Titles XVIII, XIX, or XX?...................................................................................... 0 0
C. Are there any individuals currently employed by the institution, agency, or organization in a managerial,
accounting, auditing, or similar capacity who were employed by the institution's, organization's, or
agency's fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only)........... 0 0
III. A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling
interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names
and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are
related to each other, this must be reported under"Remarks."
NAME ADDRESS EIN
B. Type of entity: o Sole proprietorship o Partnership o Corporation
o Unincorporated Associations 0 Other(specify)
C. If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations
under"Remarks."
D. Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities?
(Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses
of individuals, and provider numbers........................................................................................................... 0 0
NAME ADDRESS PROVIDER NUMBER
Exhibit H
Page 2 of 2
YES NO
IV. A. Has there been a change in ownership or control within the last year?....................................................... 0 0
If yes, give date.
B. Do you anticipate any change of ownership or control within the year?....................................................... 0 0
If yes, when?
C. Do you anticipate filing for bankruptcy within the year?................................................................................ 0 0
If yes, when?
V. Is the facility operated by a management company or leased in whole or part by another organization?.......... 0 0
If yes, give date of change in operations.
VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?......... 0 0
VII. A. Is this facility chain affiliated? ...................................................................................................................... 0 0
If yes, list name, address of corporation, and EIN.
Name EIN
Address(number,name) City State ZIP code
B. If the answer to question VII.A. is NO, was the facility ever affiliated with a chain?
(If yes, list name, address of corporation, and EIN.)
Name EIN
Address(number,name) City State ZIP code
Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be
prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the
information requested may result in denial of a request to participate or where the entity already participates, a termination of
its agreement or contract with the agency, as appropriate.
Name of authorized representative(typed) Title
Signature Date
Remarks
Revised Exhibit I
1 of 2
CERTIFICATION REGARDING DEBARMENT, SUSPENSION, AND OTHER
RESPONSIBILITY MATTERS--PRIMARY COVERED TRANSACTIONS
INSTRUCTIONS FOR CERTIFICATION
1. By signing and submitting this proposal, the prospective primary participant is
providing the certification set out below.
2. The inability of a person to provide the certification required below will not
necessarily result in denial of participation in this covered transaction. The prospective
participant shall submit an explanation of why it cannot provide the certification set out
below. The certification or explanation will be considered in connection with the
department or agency's determination whether to enter into this transaction. However,
failure of the prospective primary participant to furnish a certification or an explanation
shall disqualify such person from participation in this transaction.
3. The certification in this clause is a material representation of fact upon which
reliance was placed when the department or agency determined to enter into this
transaction. If it is later determined that the prospective primary participant knowingly
rendered an erroneous certification, in addition to other remedies available to the
Federal Government, the department or agency may terminate this transaction for
cause or default.
4. The prospective primary participant shall provide immediate written notice to
the department or agency to which this proposal is submitted if at any time the
prospective primary participant learns that its certification was erroneous when
submitted or has become erroneous by reason of changed circumstances.
5. The terms covered transaction, debarred, suspended, ineligible, participant,
person, primary covered transaction, principal, proposal, and voluntarily excluded, as
used in this clause, have the meanings set out in the Definitions and Coverage
sections of the rules implementing Executive Order 12549. You may contact the
department or agency to which this proposal is being submitted for assistance in
obtaining a copy of those regulations.
6. Nothing contained in the foregoing shall be construed to require establishment
of a system of records in order to render in good faith the certification required by this
clause. The knowledge and information of a participant is not required to exceed that
which is normally possessed by a prudent person in the ordinary course of business
dealings.
Revised Exhibit 1
2of2
CERTIFICATION
(1) The prospective primary participant certifies to the best of its knowledge and belief,
that it, its owners, officers, corporate managers and partners:
(a) Are not presently debarred, suspended, proposed for debarment, declared
ineligible, or voluntarily excluded by any Federal department or agency;
(b) Have not within a three-year period preceding this proposal been convicted of
or had a civil judgment rendered against them for commission of fraud or a criminal
offense in connection with obtaining, attempting to obtain, or performing a public
(Federal, State or local) transaction or contract under a public transaction; violation of
Federal or State antitrust statutes or commission of embezzlement, theft, forgery,
bribery, falsification or destruction of records, making false statements, or receiving
stolen property;
(c) (d) Have not within a three-year period preceding this application/proposal
had one or more public transactions (Federal, State or local) terminated for cause or
default.
(2) Where the prospective primary participant is unable to certify to any of the
statements in this certification, such prospective participant shall attach an explanation
to this proposal.
Signature: Date:
(Printed Name & Title) (Name of Agency or
Company)