HomeMy WebLinkAboutAgreement A-06-134-1 with Managed Care Master Agreement Amendment I.pdf Agreement No. 06-134-1
1 RETROACTIVE AMENDMENT I TO AGREEMENT
2 THIS AMENDMENT, hereinafter referred to as Amendment 1, is made and entered into
3 this 16th day of June , 2015, by and between the COUNTY OF FRESNO, a
4 Political Subdivision of the State of California, hereinafter referred to as"COUNTY", and
5 each PROVIDER listed in Exhibit A, "Provider(s)",attached hereto and by this,reference
6 incorporated herein, collectively hereinafter referred to as "PROVIDER(s)",and such
7 additional PROVIDER(s) as may, from time to time during the term of this Agreement, be
8 added by COUNTY with the Department of Behavioral Health(DBH) Director, or designee,
9 approval. References in this Amendment I to Agreement to "party" or"parties" shall be
10 understood to refer to COUNTY and each PROVIDER, unless otherwise specified.
11 WHEREAS, the parties entered into that certain Agreement, identified as COUNTY
12 Agreement No. 06-134, effective July 1, 2006, whereby PROVIDER(s) agreed to provide i
13 specialty mental health services to certain Medi-Cal beneficiaries; and
14 WHEREAS, the parties desire to amend COUNTY Agreement No. 06-134, regarding
15 changes as stated below and restate the Agreement in its entirety.
16 NOW, THEREFORE, for good and valuable consideration, the receipt and adequacy of
17 which is hereby acknowledged,the parties agree as follows:
18 1. That the existing COUNTY Agreement No. 06-134, Section Four(4), Page
19 Eleven(11), Line Twenty-Two (22), beginning with the word"In" and ending on Page Eleven
20 (11), Line Twenty-Four(24), with the word"Agreement" be deleted and the following inserted
I
21 in its place:
22 "In no event shall services provided by all PROVIDER(s)pursuant to the MHP
23 effective upon execution through June 30, 2014 exceed a total amount of Two Million, Five
24 Hundred Thousand and No/100 Dollars($2,500,000) for each twelve (12) month period of this
25 Agreement. In no event shall services provided by all PROVIDER(s)pursuant to the.MHP
26 from July 1, 2014 through June 30, 2015 exceed a total amount of Three Million, Five Hundred
27 Thousand and No/100 Dollars($3,500,000.00)."
28
COUNTY OF FRESNO
Fresno, CA
1 2. That the existing COUNTY Agreement No. 06-134, Section Five (5), Page
2 Twelve (12), Line Twenty-Seven (27) beginning with the word "This" and ending on Page
3 Thirteen (13), Line Three (3), with the word "period" be deleted and the following inserted in
4 its place:
5 "This Agreement shall become effective on the 1 st day of July, 2006 and shall
6 terminate on June 30, 2015."
7 3. COUNTY and PROVIDER(s) agree that this Amendment I is sufficient to amend
8 the Agreement; and that upon execution of this Amendment I, the Agreement, and Amendment
9 I together shall be considered the Agreement.
10 The Agreement, as hereby amended, is ratified and continued. All provisions,
11 terms, covenants, conditions and promises contained in the Agreement, and not amended herein,
12 shall remain in full force and effect. This Amendment I shall become effective retroactive to
13 July 1, 2014.
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COUNTY OF FRESNO
Fresno, CA
1 IN WITNESS WHEREOF, the parties hereto have executed this Amendment I to
2 Agreement No. 06-134 as of the day and year first hereinabove written.
3
4 PROVIDER(S): COUNTY OF FRESNO
SEE ATTACHED EXHIBIT A
5
6 B O .
Y
7 Deborah A. Poochigian
Chairman, Board of Supervis s
8
Date:
9
i
10
11
BERNICE E. SEIDEL, Clerk
12 Board of Supervisors
13
14
By
15
16
17 Date: :u-,,-p— 1 i> a D 15
18 ;
19
PLEASE SEE ADDITIONAL
20 SIGNATURE PAGE ATTACHED
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COUNTY OF FRESNO
Fresno, CA
1
APPROVED AS TO LEGAL FORM:
2 DANIEL C. CEDERBORG, COUNTY COUNSEL
3
4
5 By
6
APPROVED AS TO ACCOUNTING FORM:
7 VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
8 TREASURER-TAX COLLECTOR
9 � r
10 By
11
12
REVIEWED AND RECOMMENDED FOR
13 APPROVAL:
14
15
By ,C A-a��
16 Dawan Utecht, Director
17 Department of Behavioral Health
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19
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21 Fund/Subclass: 0001/10000
22 Organization: 56302666
Account/Program: 7223/0
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24
25
26 Fiscal Year (FY) Program Cost
FY 2006-07 through FY 2013-14 $2,500,000.00 (Each FY)
27 FY 2014-2015 $3,500,000.00
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4 -
COUNTY OF FRESNO
Fresno, CA
Exhibit A
Individual Providers
Name Address
AI-Saoudi, Yuleen 516 Villa Suite#3 Clovis, CA 93612-
Amling-Heiken,Jane 5464 N. Palm #B Fresno, CA 93704-
Armer,Justin 614 N. St Sanger, CA 93657-
Avina, Erica 614 N. Street Sanger, CA 93657-
Bergstrom, Virginia 5588 N. Palm Fresno, CA 93704-
Broesel, Rondi 4747 N. First, Suite 119 Fresno, CA 93726-
Brookins, Antionette 3723 E. Dakota Fresno, CA 93726-
Cardoza,Julie 2490 W. Shaw Ave Suite 101 Fresno, CA 93710
Case, Gabriele 4420 N. First #121 Fresno, CA 93726-
Casillas,Jennell A. 6225 N. First Street Suite 103 Fresno, CA 93710
Dickey,Judith 5707 N. Palm #103 Fresno, CA 93704
Fulton,Tracy 5464 N Palm Ave, Ste # B Fresno, CA 93704-
Garvey, Catherine 5475 N. Fresno Street Fresno, CA 93710
Glidden, Howard, Dr. 1660 E. Herndon#150 Fresno, CA 93720-
Gordon-McIntosh, Wanda 5588 N. Palm Ave Fresno, CA 93704-
Haider, Shazina, Dr. 416 W Bluff Ave Fresno, CA 93711
Jackson-Salcedo, Peggy, Dr. 1586 N. Van Ness Fresno, CA 93728-
Johnson, David 3097 Willow Ave Suite #4 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, Dr. 5100 N. Sixth#135 Fresno, CA 93710
Pacheco, Myrna 5588 N. Palm Ave Fresno, CA 93704-
Powroznik,James 5588 N. Palm Ave Suite P4 Fresno, CA 93704-
Qualle, Cordie Micah 264 Clovis Ave Ste 212 Clovis, CA 93612-
Randolph, Michelle 5070 N. Sixth #174 Fresno, CA 93710-
Roltgen, Teresa 2505 W. Shaw Fresno, CA 93711-
Romero,Jorge 5070 N. Sixth #174 Fresno, CA 93710-
Slagle, Laura 3114 Willow Ave Ste 102 Clovis, CA 93612-
Steele, Ronald 7005 N Milburn Ave, Suite 202, Fresno, CA 93722
Trujillo, Elinda 1713 Tulare St Suite 132 Fresno, CA 93721-
Xiong, Zoua 5588 N. Palm Avenue Fresno, CA 93704
Young, Perry 5707 N. Palm #103 Fresno, CA 93704-
Ziyar, Latif, Dr. 7335 N. First#109 Fresno, CA 93720-
Group Providers
Name Address
Bashful Elephant Counseling 3097 Willow Ave Suite#4 Clovis, CA 93612-
Castani Family Services 5100 N. 6th Ste 104 Fresno, CA 93710-
DN Associates 3457 W Shaw Ave#101 Fresno, CA 93711
Dunamis, Inc 4991 E.McKinley#112 Fresno, CA 93727-
Fresno Mental Health 1130 E. Shaw Ste 105 Fresno, CA 93710-
Generational Changes, Inc. 2409 Merced Ste 106 Fresno, CA 93721-
House Psychiatric Clinic, Inc 1322 E. Shaw#410 Fresno, CA 93710-
Kids Play Therapy, Inc. 5100 N. Sixth#140 Fresno, CA 93710-
Page 1 of 1
1 PROVIDER: Yuleen AI-Saoudi
2
3 BY
4
5 Print Name:
6 Title: L 1 if T
7
r l}
8
Date:
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10
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12
13 Mailing Address:
14
516 Villa Suite #3
15 Clovis, Ca. 93612
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COUNTY OF FRESNO
Fresno, CA
i F"
PROVIDER: Jane Amling-Heiken
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3
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5 Print Nam&r�
6 Title:
7
Date:
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13 Mailing Address:
14
5464 N. Palm #13
15 Fresno, CA 93704
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Justin Armer
2
3 $y
4 f
5 Print Name:
6 Title: L-17 �
7 p
8 Date: `fit t
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13 Mailing Address:
14
614 N. St
15 Sanger, Ca. 93657
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Erica Avina
2 13 -
Y
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4 Print Name: ,r i �UL. A--
5
Title: l- Y1 S
6
7 Dater
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13 Mailing Address:
14 614 N. St
Sanger, Ca. 93657
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COUNTY OF FRFSNO
Fresno, CA
1 PROVIDEi: Virginia Be strom
2 z f
By 2,
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4 Print Name: C'j 41,
'
5 y��Title: t—
_
6 f /
7 Date:
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13 Mailing Address:
14 5588 N. Palm
Fresno, CA 93704
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COUNTY OF FRESNO
Fresno, CA
M�
1 PROVIDER• Rondi Broesel
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By
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� t
4 Print Name:
5 Title: j
6
7 Date:
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13 Mailing Address:
14 4747 N. First, Suite 119
15 Fresno, CA 93726
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COUNTY OF FRESNO
Fresno, CA
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1 PROVIDER: Antionette Brookins
2 By
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4 Print Name: e1
5
Title:
6
7 Date:
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13 Mailing Address:
14 3723 E. Dakota
15 Fresno, CA 93726-
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COUNTY OF FRESNO
Fresno, CFI
1 Julie Cardoza
2
3 B
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5 Print Name:\� e,
6 Title: ; ��
7 _
8 Dater � {
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13 Mailing Address:
14 2490 W. Shaw Ave Suite 101
Fresno, CA 93710
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Gabriele Case
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r�
By
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4 Print Name: v�1 ,4)
5
Title: G�,�
6
7 Date: - (- b
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Mailing Address:
13 / 4/5/ L) 5hAw
-d ;4 AT L4 t +�1 7 1
14
Fresno, CA 9372('
15 It
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COUNTY OF FRESNO
Fresno, CA r
� r
1 PROVIDER: Jennell A Casillas
2
3 BY
4
Print Name: I�GWA941 as i ll4lf
5
6 Title: LMPT 91M
8
Date: os
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13 Mailing Address:
14 6225 N. First Street, Suite 103
Fresno, CA 93710
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Judith Dickey
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2 By 11 r
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4 Print Name:
5
Title: ZA//-
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7 Date:
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13 Mailing Address:
14 5707 N. Palm #103
Fresno, Ca. 93704
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COUNTY OF FRESNO
Fresno, CA
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1 PROVIDER: Tracy Fulton
2
By
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4 Print Name: /rIfC' c'fT�')
5
Title: 1,WFT
6
7 Date:
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13 Mailing Address:
14 5464 N Palm Ave, Ste # B
Fresno, CA 93704
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COUNTY OF FRESNO
Fresno, CA
1'7
1 PROVIDER: Katherine Garvey
2
By
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4 Print Name:
5
Title: �'v�/,
6
7 Dater
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13 Mailing Address:
14 5475 N Fresno Str.
Fresno, Ca. 93710
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COUNTY OF FRESNO
Fresno, CA t
t
1 PROVIDER: Howard Glidden
Y
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4 Print Name: J'J ,
5
Title:
6
7 Date: 5-111/7ai r-
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13 Mailing Address:
14 1660 E. Herndon 4150
Fresno, CA 93720
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COUNTY OF FRESNO
Fresno, CA
i�
1 PROVIDER: Wanda Gordon-McIntosh
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2 14,1e
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4 Print Name:/Z/Ak/z-
5 Title: '4 ) �
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7 Date: S ` d-
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Mailing Address:
13
14 5588 N. Palm Ave
Fresno, CA 93704
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Shazina Haider
2 By
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4 Print Name:,S' A Zf tiA
5 Title:
6
7 Date:
8 - t —__f
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13 Mailing Address:
14 416 W. Bluff Ave.
Fresno, Ca. 93711-6908
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Dr. Peggy Jackson-Salcedo
� f
2
a" �
3
4 Print Name: ' `�.�` 1
5 r� V. �� �S > > S �
Title: S_-� �= �--� '� -�" �� cl
6
7 Dater
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13 Mailing Address:
14 1586 N. Van Ness
Fresno, CA 93728
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDE Johnson, id
2 � -
By
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4 Print Name:
5 it
Title:
6 ,
7 Date: / � 5
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Mailing Address:
13
14 3097 Willow Ave Suite 94
Clovis, CA 93612
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Jeanette Lopez
2 By
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4 Print Name: `lEr1i w He T
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Title: 4 0,5 k j
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7 Date:
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13 Mailing Address:
14 2008 N. Fine #103
Fresno, CA 93727
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Linda Lose
2
By
3 ' 1
4 Print Name:
5 Title:
6
7 Date: 5
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13 Mailing Address:
14 1305 W. Bullard 411
Fresno, CA 93704
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COUNTY OF FRESNO
Fresno, CA
1 PR ID : Matthew I Malin
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3
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5
Print Name:
6 Title:
7 �^
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Date:
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13 Mailing Address:
14
264 Clovis Ave Ste. 212
15 Clovis, Ca. 93612
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Jeffrey B. Mar
2
3 By
4
111-2-
5
Print Name: �� ��"��`—J� r� ✓� JGLi, ,
6 Title: p5-7 t 1 9
7
8 Date: ✓ 1� S�
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10
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13 Mailing Address:
14
5100 North sixth Street #135
15 Fresno, Ca. 93710
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COUNTY OF FRESNO
Fresno, CA
a�
1 PROVIDER: Myrna Pacheco
3 By
4
5 Print Name: b �
6 Title:
7
8 Date: E 1
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13 Mailing Address:
14 5588 N. Palm Avenue
Fresno, CA 93704
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COUNTY OF FRESNO
Fresno, CA
1 James Powroznik
2
3 BY
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5 Print Name: J-rh.� -
6 Title:
7
8 Date: ' --1 c�
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10
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13 Mailing Address:
14 5588 N. Palm Ave
Fresno, CA 93704
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Cordie Micah Qualle
2
3 By 0'zz::�
5 Print Name: '
6 Title: L-'t
7
8 Date:
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13 Mailing Address:
14
264 Clovis Ave # 202
15 Clovis Ca 93612
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COUNTY OF FRESNO
Fresno, CA hh
Jt''
1 PROVIDER: Michelle Randolph
2 _
3 By
4
5 Print Name:
6 Title:
7
8
Dater
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13 Mailing Address:
14
5100 N Sixth Street
15 Fresno, Ca. 93710
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Teresa RoUgen
2
3 By
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5 Print Name: c� . �M
6 Title: --�
7
8 Date:
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10
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13 Mailing Address:
14 2505 W. Shaw Avenue
Fresno, CA 93711
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Jorge Romero
2
3 By
Print Name:
5
6 Title:
Date:
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10
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13 Mailing Address:
14 5070 N Sixth Street, Suite 174
Fresno, CA 93710
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Laura Slagle
2
3 By C�
4
5 Print Name:
6 Title: L. VY1 (_ T
7
8 Date: 0 19 1S
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10
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12
13 Mailing Address:
14 3114 Willow Avenue, Suite 102
Clovis, CA 93612
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Ron C Steele
2
3 By
5 Print Name:
6 Title:
7
8 Date: S __
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13 Mailing Address:
14 7005 N. Milburn Avenue, Suite 202
Fresno, CA 93722
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Erlinda Trujillo
2
By
3 -k&L
4
Print Name: C
5
6 Title:
7
8 Date:
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13 Mailing Address:
14 2848 Mariposa Street
Fresno, CA 93721
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COUNTY OF FRESNO
Fresno, CA
�G
1 Zoua Xiong
2
3 By� (_
4 C - L-�11 11-11��
5 Print Name: -76 C) x t'ovc2
6 Title: 1 Lt.� 4 c,,.(�{�
7 a
8 Date: I q I,S
9
10
11
12
13 Mailing Address:
14 5588 N. Palm Ave
Fresno, CA 93704
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COUNTY OF FRESNO
Fresno, CA !
1 PROVIDER: Perry Young
2 /
3 By �
4
5 Print Name: CJ _
6 Title: L /n22 n�2s
7
8 Date:
9
10
11
12
13 Mailing Address:
14 5707 N. Palm Avenue, Suite 103
Fresno, CA 93704
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COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: Latif Ziyar
3 y +"
4
5 Print Name: Z t31
6 Title:
8 Date:
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13 Mailing Address:
14 7335 N. First Street, Suite 109
Fresno, CA 93720
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COUNTY OF FRESNO
Fresno, CA
I PROVIDER: BASHFUL ELEPHANT COUNSELING
2
3 B y
4
5 Print Name: �� t CIA U tf i�5.
6 Title: t'm f— F
Chairman of the Board, or
President, or any Vice President
8 r
9 Date:
10
11 By:
12
13 Print Name:
14
15 Title:
16 Secretary (of Corporation), or
any Assistant Secretary, or
17 Chief Financial Officer, or
18 any Assistant Treasurer
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1 - COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: CASTANI FAMILY SERVICES
2
3 By jZka
4 _ 0
G -
5 Print Name:��I (.l,a a
6 Title: L
Chairman of the Board, or
7 President, or any Vice President
8
9 Date: --`` 20 L
10
11 By:
12
13 Print Name:
14
15 Title:
16 Secretary (of Corporation), or
any Assistant Secretary, or
17 Chief Financial Officer, or
18 any Assistant Treasurer
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1 - COUNTY OF FRESNO
Fresno, CA
9
1 PROVIDER: DN Associates
2
3
By eA,,-..
4
5 Print Name: -kz-r C ti A 1-j
6 Title: -t C'2 -
Chairman of the Board, or
7 President, or any Vice President
8
9 Date:
10
11 By:
12
13 Print Name:
14
15 Title:
16 Secretary (of Corporation), or
any Assistant Secretary, or
17 Chief Financial Officer, or
18 any Assistant Treasurer
19
20
Mailing Address:
21
3457 W Shaw Ave#101
22 Fresno, CA 93711
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1 - COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: DUNAMIS, INC.
2
3
By /
4
5 Print Name: ( 5-)
6 Title: C E L)
Chairman of the Board, or
7 President, or any Vice President
8
9 Date:
10
11 By:
12
13 Print Name:
14
15 Title:
16 Secretary (of Corporation), or
any Assistant Secretary, or
17 Chief Financial Officer, or
any Assistant Treasurer
18
19
20 Mailing Address:
4991 E. McKinley, Suite 112
21 Fresno, CA 93727
22
23
24
25
26
27
28
1 - COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: FRESNO MENTAL HEALTH
2
3 By
4
Print Name: Mx' .'/yt, -2 � t�
5
6 Title:
Chairman of the Board, or
7 President, or any Vice President
8
9 Date:
10
11 By:
12
13 Print Name:
14
15 Title:
16 Secretary (of Corporation), or
any Assistant Secretary, or
17 Chief Financial Officer, or
any Assistant Treasurer
18
19
20
21
22
23
24
25
26
27
28
] - COUNTY OF FRESNO
Fresno, CA
"t
1 PROVIDER: GENERATIONAL CHANGES, INC.
2
3
By
4
5
Print Name:
6 Title:
Chairman of the Board, or
7 President, or any Vice President
8
9 Date:
10
11 By:
12
13 Print Name:
14
15 Title: (�t�l
16 Secretary (of Corporation), or
any Assistant Secretary, or
17 Chief Financial Officer, or
any Assistant Treasurer
18
19
20
21
22
23
24
25
26
27
28
1 - COUNTY OF FRESNO
Fresno, CA
I PROVIDER: HOUSE PSYCHIATRIC CLINIC, INC.
2
3
By
4 _
Print Name: //j/jCW ✓5G
5
6 Title:
Chairman of the Board, or
7 President, or any Vice President
8
9 Date:
- Cl - 6
10
11 By:
12
13 Print Name:
14
15 Title:
16 Secretary (of Corporation), or
any Assistant Secretary, or
17 Chief Financial Officer, or
any Assistant Treasurer
18
19
20
21
22
23
24
25
26
27
28
1 - COUNTY OF FRESNO
Fresno, CA
1 PROVIDER: KIDS PLAY THERAPY, INC.
2
3 y¢
By C.1
4
5 Print Name: 1 1
6 Title:
Chairman of the Board, or
7 President, or any Vice President
8
9 Date:
10
11 By:
12
13 Print Name:
14
15 Title:
16 Secretary (of Corporation), or
any Assistant Secretary, or
17 Chief Financial Officer, or
any Assistant Treasurer
18
19
20
21
22
23
24
25
26
27
28
1 - COUNTY OF FRESNO
Fresno, CA p �
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