HomeMy WebLinkAboutAgreement A-09-022-3 with Psychological Institute, Inc..pdfAgreement 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 Q...rv~ day of 0\: .LJ\ ll .. , 2015, by and between the COUNTY OF FRESNO, a Political
4 Subdivision ofthe 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 II (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 ofHealth 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 ofwhich 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
2 4 Revised Exhibit C-2, which is attached hereto and incorporated herein, shall be the
2 5 basis for reimbursement to PROVIDER for rendering Covered Services to Members, at the prevailing
2 6 fee-for-service reimbursement rates of payment for provider services, identified in Revised Exhibit D-2
2 7 "Provider Fee Schedule", which is attached hereto and incorporated herein, at the time such specialty
2 8 mental health services are rendered. If Members have other health insurance coverage, PROVIDER
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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 ofthe COUNTY.
10 In no event shall services provided by PROVIDER during the term ofthis
11 Agreement exceed:
12 1) One Million, Five Hundred Thousand, One and Nol1 00 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 Nol100 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 Nol100 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 Noll 00 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 Nol100 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 Nol1 00 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 NollOO Dollars ($3,207,701.00), for the period of July 1, 2015 through June 30,2016.
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COUNTY OF FRESNO
Fresno, CA
1 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 ofthis 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 1st day of January 2009 and shall
9 terminate on the 30th day of June 2009.
1 0 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.
2 0 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 (1 0%) of the maximum compensation payable to
2 2 the PROVIDER, and changes to the service volume/types of service units to be provided as set forth in
2 3 Revised Exhibit C-2, may be made with the written approval of COUNTY's DBH Director, or
2 4 designee. Said budget line item and service volume/types of service units changes shall not result in
2 5 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:
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COUNTY OF FRESNO
Fresno, CA
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6 5.
"E. Sexual Abuse I Molestation Liability
Sexual Abuse I Molestation Liability Insurance (including but not limited to
corporal punishment liability, sexual abuse and molestation liability, and child
abduction liability) with limits of not less than One Million Dollars ($1,000,000)
per occurrence, Two Million Dollars ($2,000,000) annual aggregate. This policy
shall be issued on a per occurrence basis."
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 ifPROVIDER is a disclosing entity, fiscal agent,
11 or managed care entity as defined in Code ofFederal Regulations (C.F.R), Title 42 § 455.101
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 ofthis 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
2 0 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
2 3 PROVIDER is required to disclose if any of the following conditions apply to
2 4 them, their owners, officers, corporate managers and partners (hereinafter collectively referred to as
2 5 "PROVIDER"):
26 A. Within the three-year period preceding the Agreement award, they have
2 7 been convicted of, or had a civil judgment rendered against them for:
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COUNTY OF FRESNO
Fresno, CA
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8 B.
1.
2.
3.
4.
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 a federal or state antitrust statute;
Embezzlement, theft, forgery, bribery, falsification, or destruction
of records; or
False statements or receipt of stolen property.
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.
1 0 Disclosure of the above information will not automatically eliminate
11 PROVIDER from further business consideration. The information will be considered as part ofthe
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 ofthis 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.
2 4 PROVIDER shall indemnify, defend and hold the COUNTY harmless for any loss or damage
2 5 resulting from a conviction, debarment, exclusion, ineligibility or other matter listed in the signed
2 6 Certification Regarding Debarment, Suspension, and Other Responsibility Matters."
27 6. That the existing COUNTY Agreement No. 09-022, Sections 9.15 (Non-Exclusive
2 8 Contracts) through 9.19 (Entire Agreement) be renumbered to read Sections 9.17 through 9 .21.
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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
9.
10.
That Exhibit G is deleted in its entirety.
COUNTY and PROVIDER agree that this Amendment III is sufficient to amend
10 Agreement No. 09-022. Amendment I, Amendment II 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.
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COUNTY OF FRESNO
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IN WITNESS WHEREOF, the parties hereto have executed this Amendment III to Agreement as
of the day and year first hereinabove written.
PROVIDER:
CALIFORNIA PSYCHOLOGICAL
INSTITUTE, INC.
By5.~· Prin~ tAj DWtl~:
Title: Q.&D
Chairman of the Board, or
President, or any Vice President
By':1f\/lu~~
PrintName: fY'\lrJ1e-flc l>kdJttot;
Title: ~
Secretary (of Corpo ton), or
any Assistant Secretary, or
Chief Financial Officer, or
any Assistant Treasurer
Mailing Address:
1470 W. Herndon Avenue, Suite 300
Fresno, CA 93 711
Phone No.: (559) 256-2000
COUNTY OF FRESNO
By~~~~~~a_~~~~~
Chairman, Board of Supervisors
Date: C}v J J.{)J 5" ' 7
BERNICE E. SEIDEL, Clerk
Board of Supervisors
Date: '0""\...u'-L ')_ 1 2o \'5'
PLEASE SEE ADDITIONAL
SIGNATURE PAGE ATTACHED
Contact: Michelle Owhadi, Administrative Director
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COUNTY OF FRESNO
Fresno, CA
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APPROVED AS TO LEGAL FORM:
DANIEL C. CEDERBORG, COUNTY COUNSEL
APP OVED AS TO ACCOUNTIN'-"'*"~J."\.HJ
VICKI CROW, C.P.A., AUDITOR-CONTROLLER/
TREASURER-TAX COLLECTOR
By Or& ~&-<-<RJ
REVIEWED AND RECOMMENDED FOR APPROVAL:
By .~[)'{;(-;lu,li nawanuteCi1i,Di
Department of Behavioral Health
REVIEWED AND RECOMMENDED FOR APPROVAL:
Delfino E. eira, Director
Department of Social Services
Fund/Subclass: 0001/10000
Organizations: 56302666
Accounts/Programs: 7223/0
21 Fund/Subclass: 0001/10000
22
23
24
25
26
27
28
Organizations: 56107001 (Non-medical billable services for DSS consumers only)
Accounts/Programs: 7870/0
Fiscal Year Maximums:
11112009-6/30/2009: $1,500,001
FY 2009-10: $3,090,001
FY 2010-11: $3,182,701
FY 2011-12: $3,114,273
FY 2012-13: $3,207,699
FY 2013-14: $3,207,701
FY 2014-15: $3,600,000
FY 2015-16: $3,207,701
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COUNTY OF FRESNO
Fresno, CA
Revised Exhibit C-2
California Psychological Institute
Budget Period-July 1, 2014 to June 30, 2015
Budget (;ateg_ories -___ _
Line Item Description (Must be itemized)
PERSONNEL SALARIES:
0001 ____ ]f~nica! [)irector __ __ _ ___ _
0002 :Psychiatrist! f--· --.... -·--+ --------" ------···-------
0003 ___ Jf~!liCi(inS ( ln!ern~}__ __ _ r------
0004 _ +(;linicans ( Li~~nsecl)
0005 _ _ 1 Case_ Ma_nag_~s__ _ _____ _
~!5-~A~_min{Supee>!! Staff
j .. ----
i SALARY TOTAL
PAYROLL TAXES:
s_030 ____ jQ~S_[)!__L_ _
0031 IFICA/MEDICARE oo32 ___ ----r u.T ___ --------------------
PAYROLL TAX TOTAL
EMPLOYEE BENEFITS:
0040 :Retirement 1
1------·j···-------"
0041 I Workers Compensation
~04_2___ 1 Healthlnsurance (medical-vision, life, dental)
I EMPLOYEE BENEFITS TOTAL
SALARY & BENEFITS GRAND TOTAL!
FACILITIES/EQUIPMENT EXPENSES:
1010 f--·-
1011 r------
1012 1------
1013
----·-
1014
1015
· RenULease Building -+------------
1 RenULease Equipment t ---------------
,U_ti_lities _ -I
[Janitorial 1
I Common Area Maint.
1·--·------------··-------------
Maintenance (facility)
I FACILITY/EQUIPMENT TOTAL
OPERATING EXPENSES:
1 06~ __ --~~lej>l1_()!1.!_ __
1_9§_! _ _ , AJ'l_s_welj_ng S~IVic~!_§ch~~-u_li_ng
1 062 ' Postage t---------
1 06~ _ JP_I'Lntil'l_g/Reproducti.e>_n/A~v~r_tLsLng __ _
1 064 I Publications
---.. --~--------
1065 :~g(il
1066 _ -~()ffice -~llPP_Ii~-~ Equi~ent
1067 :Household Supplies 1o68--~F~od ___ ,--· -------
1o69 _____ --ip~ogram supplies----
1--··---------------------
1070 :Program Supplies -Psych Testing ~---·---+------··--~ -----·--------------------
~0]_!__ . .l Tn:m~port~tion of Cli_~nt!; __
1 072 ·Staff Mileage/vehicle maintenance
---+
FTE%
1.00
0.60
8.00
6.00
10.00
10.00
35.60
.
1 Page 1 of 4
Total Proposed Budget
Admirl~--r-------oirect-----Total
$65,000 $60,000 $125,000
--------· ------------~--·-----· --~
$145,600 $145,600
------·-------------------
$428,480 . -----~428,480
.. $480,000 --~480,000
$3 ___ 7 __ 7._,0_00-t ------~~?7~QQQ
$_~6."!00 ---------~686,400
---
$751,400
. ----
$0
------
$0
. -----t--
-----------·--
$0
$1,491,080 $2,242,480
$130,007
------.. ---·--__.___
..... --. $30,_4Q§
$10,217
$0 $170,629
$60,000
-------~--· ------
$10,500
-------. ------··-'-----
$200,000
$0 $270,500
$2,683,609
-1----$266,075
$4,000 ---r--------
$27,000
----'-----
$31,620
.. --~-··---
$10,000 -1-----------
$10,000
$348,695
i $17,425
---~-t -----· ---------+---$3~6_QQ
: $2,200
---~ ---1··--·· --------
-------·-·· ·-~3.000 ------+-----$360
t --------_$3,_~
$25,000
-~-··
$9,500 ____ _,_ ______ ·--~----
$10,000
--~ ; ----
-r
--t---
1 -+ I $15,000
------. -----
-$3,JQQ
$2,500
·------
$61,993
; Staff Training/Registration I -----------------
Administrative Overhead
1073
C---------
1074
]OPERATING EXPENSES TOTAL
FINANCIAL SERVICES EXPENSES:
1080 __ J A~co_l.mting/Bc:>ok_keepin_g __ _
c1Q_~! J Liabiljt~ 111§_uran~e ______ _ __ _
1 082 'Payroll Processing -
--------t-
!FINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (Consultant/Etc.):
~-~ ____ Sonsultant (n~twork &_dat~~anagernent)
1 084 i Translation Services
---~----------------------
1 085 _ LEie~£()nic He~l~h R~co~_
1 086 I Incentive Program
t !SPECIAL EXPENSES TOTAL
FIXED ASSETS:
2001 I Furniture & Fixtures ---------------r;------------------
2003 ,other
I FIXED ASSETS TOTAL
'
_j ___ -----
1
Revised Exhibit C-2
Page 2 of4
I ----1----
! --------: ---1!~:~~~
-----~~ --t---
--t i ______ _
$229,199
i
I $25,055 ---------+------
$28,986 ----------
$23,000
$77,041
___ l6_0,Q_QQ
$1,000
----------
---_,
----i ----
1
' -4------
$20,000
$122,456
$203,456
$48,000 -----
$10,000 ------
$0
1
1 $58,000
TOTAL PROGRAM EXPENSES $3,600,000 --__ ,____ -----------------------_______ ....... ___ -!
--
-----r----------------
----------__ __j__________ - - -
PROJECTED REVENUE: Volume Rate $ Amount
1 '05_1_,_~_1_ 4 3000 , Mental Health Services
----------_j2.61 --__ $2,743,9~1 --I --
__ __, ___ 1 (A~!BSS"!_entf'~a_f'l_o_f Ca~, lrl_dividuafiE_afTiiiYIGf()up_ Therapy. _Rehab) $0
~100 -~~ Cas_e Man(igem~nt, Linka_g_e/Brokerage __
3200 Crisis Intervention 1-----~---- ------------------
168,513 ----$2.02 ----$~40,396
310 $3.88 $1,203
----------------~
~~9_0 _ -~~di~ation_§upp()r!_ __ : _ -~~_Q_OO _______ $4._~ ____ $207,260
~QQ ____ l (;oJ~ate_l'~l __ __ _ _
3500 i Court Documentation, Report, Appearance ~~f~ ~·-=----ift~chologic~l e~~~ationl~~nding-~tudy -----
3aoo--~ --l1Hss___ -------- - - --
r-----!-----,------------ -
3900 1
1
other
37,000 $2.61 $96,570
-------------------'-----
900 $60.00 $54,000 ----c---------------------------
--43,246 -----$3.61 ____ $156, 118
200 $2.61 $522
--------------------------------
0 $2.61 $0
-------------------------
0 $0.00 $0
r----
! TOTAL PROJECTED REVENUE 1,344,483 $3,600,000
-------------
$1,800,000
~--
'Medl:cal R~~enue
Cost P-eiu~it ___ l ---
----__ _J_
I
2.677608146
Revised Exhibit C-2
California Psychological Institute
Budget Period -July 1, 2015 to June 30, 2016
_f3l!dget 9Ci~gorie~-=------------
Line Item Description (Must be itemized)
PERSONNEL SALARIES:
~0_1 __ j gli!'lical Djl'_ect~-
~<g __ -+P~ycbi=at:::..:ri=st'--------·
0003 ! Clinicians (Interns) r----t---·----·-------·--·---·
0004 Clinicians (Licensed) ----,------------------
()005 --1 Case_l\nana_g~rs_ _ _
0006 !Admin/Support Staff
SALARY TOTAL
PAYROLL TAXES:
0030 _ )OASDI_
0031 FICA/MEDICARE
0032 1U.I.
;PAYROLL TAX TOTAL
EMFI!-:O~EE BEJ'JEFil§_:__
Q_04Q __ J RetirerTI~ __
0041 1 Work~!_Gomp~ns_Cl_ti_on
0042 Health Insurance (medical, vision, life, dental)
1 EMPLOYEE BENEFITS TOTAL
SALARY & BENEFITS GRAND TOTAL I
FACILITIES/EQUIPMENT EXPENSES:
1010 JREmt/L_ease Buildin_g
1Q_1J ~ R_~t/ Lee~se_ Equipment ___ _
~g 1_~--_i_LJ_tiliti~s ___ _
_1Q13 J..lCi_l}itQriaL_ ___ _
1014 [Maintenance (facility)
I FACILITY/EQUIPMENT TOTAL
OPERATING EXPENSES:
1060 !Telephone ---··--+-----------·---
_1_@1 _JAns~ering S~Qd_c:e
1 062 _-~~stage ..
1 063 I Printing/Reproduction/Advertising --------1· ---·----· .. ---·-·--·-. --
1 064 __ ,Publicati_ons
1 065 J Legeil__ __
1 066_. _J.Qffice _§uppli_es &_ Equipm~!'lt
1 067 ! Household Supplies r-----·--·•··--·---· -----··--··-·--
1068 ,Food r--+---------··
~~ i PrQ9rCill1_~upplie_!_ __ _
1070 --~_r9gram SlJpplies -psych Tel)ting
1071 !Transportation of Clients
Page 3 of4
Total Proposed Budget
----·-
FTE% --Admin. --j .. Direct Total
1.00
0.60 ------r·
8.00
6.00
10.00
10.00
35.60
-----
···--·
-+
' I
-----·
-------·
$599,000
$599,000
$0
---f-
$0
i
--$122,500
-~145,600
___ !gg,50Q
____!11.5_,_6_()_0
$428,480 $428,480
----------. -
$420,700 $420,700 --. .. ··----r-----------·-
$377,000 $377,000
··------··-----·--
$599,000
$1,494,280 $2,093,280
-----·
----______ $1~0,756
$28,241
------·-----··-~-
$10,218
$0 $159,215
-----· ·----
$59,000
----·------·----~
$10,500
------------· -------
$190,000
$0 $259,500
$2,511,995
----____ $26_6,075
... $20,099 ---
$27,000 ---------._ _
---------_$~ 1p20
$15,000
$359,695
$10,000
-------
i ------$3,600
i ~200 ---j -----------------
i ----t
$3,000
-----·· -------··-
$360
----
--~~.500
$30,000 ·---____ __.___
$9,500
------·-------
$12,000
------· -·· ·----
---------~1 0_d0_9
---· ---.. -$3,7_Q()
$2,000
1 072 Staff mileage/vehicle maintenance
~--------,-----------------------------
c1-073_ __ jstaff Training/Registration ___ _
1 07 4 1 Administrative Overhead
I oPERATING EXPENSES TOTAL
FINANCIAL SERVICES EXPENSES:
1 080 ! Accounting/Bookkeeping f--------' ------------
!0~_1_ __ lLiC)bility Insurance ____ _
1 082 1 Payroll Processing
jFINANCIAL SERVICES TOTAL
SPECIAL EXPENSES (Consultant/Etc.)
J083 -i Con~ultant (neJ'Norl<_& da_t~ m<!_nage111e11t}
1Q_8_4 _ J Tran~lation Servi~e_s ___ _ ______ _
1Q~LjE:Iec=tronic _l:lea_!th Record __ _
1086 ;
1
1ncentive Program
jSPECIAL EXPENSES TOTAL
FIXED ASSETS:
I
2QOQ __ j_QQmputers ~Softwar~
2001 . Furniture & Fixtures
---------j----------------
2002 \Other
I FIXED ASSETS TOTAL
!
1---------------
PROJECTED REVENUE:
3000 , Mental Health Services
------j---------------
___ _ _{Assessment,_ Plan of Carf],_lndiVJ_(}_ua/!Farmlyi_Group Thf!!_apy, Rehab)
~ --
~00 ___ ;c~e Manageme'lt ~il'lkage/Broker(ige __ _ __ _ ---
3200 I Crisis Intervention -----t--------------------
~ [~edi~tio11__Support _____ _
Youth Link & Other Services
-----· ------------------------
3400 I Collateral
----~-----------------------
3!)0_Q__~ourt _Q_ocllmen_!_ati_o_ll_,_R~Port Appea_r-C)nce _
~00 __ --f~yc_l'lologi~l evC)IuatiQ_11 __ ______ _ __ _
3700 \ICC -------t----------------------
3800 UHB§ ----------------------- -
3900 :other
TOTAL PROJECTED REVENUE
i
I
- ---l
----l--
1
!
Revised Exhibit C-2
Page 4 of4
-------1-----$~,000
$10,000
-------------------
$13,990
$159,150
$9,500 ---r-----------
--f------____R~.~~§
$30,000
$68,486
---------1----
--------1-----_$_1_,_Q_Q_Q
$20,000 ------r-----------
$50,375
$99,375
r-----$4,500
------
$4,500
----r---
$0
$9,000
TOTAL PROGRAM EXPENSES $3,207,701 ____ ....... ___;,...,;.......;~-1
I
Volume Rate $Amount
---~65,94_§_ __ --l2.61---__ $_1,216,116
-------r----------
2~Q~Q_~O $2.02 $484,881
-------------------------~
600
------------f---~3.88 ----$2,3~f!
-
1_4_9~920 $4.82 $722,614
---------------------
------------------------
1~-5_~000 ---r-$2.61 --------~?6_.?__§_9_
2,000 -f--$60.00 ----____jj_~~Q_Q_Q_
_§_?,40Q__ r----$3.61 -------$225,264
__ 42,0_00_ -r-----$2.61 -_____ $~ 09,620
240 $2.61 $626 ---------r------------------------
0 $0.00 $0
1,088,145 $3,207,701
Cost Per Unit $3
--Pr~;~tedCostSettl~ment Due C~unty or (Due -Co~~~c~ -------r ----------
$0
Revised Exhibit D-2
PROVIDER FEE SCHEDULE
July 1, 2015 through June 30, 2016
CALIFORNIA PSYCHOLOGICAL INSTITUTE
Service Description
Mental Health Services:
Individual Assessment: Non-MD X9504M
Individual or Family Therapy: MD X9601M
Individual or Family Therapy: Non-MD X9600M
Group Therapy: Non-MD X9506M
Group Rehabilitative X9505M
Collateral: Non-MD X9546M
Rehabilitation X9055M
Plan Development X9054M
Test Administration: Non-MD X9516M
ICC
IHBS
Case Management Services:
Case Management: Linkage, Consultation, Placement X9205M
Crisis Services:
Crisis Intervention ED: MD 99283M
Crisis Intervention ED: Non-MD X9031M
Medication Support Services:
Meds Interview: MD 90862M
Services for Court Referred Cases
Psychologist
Psychological Evaluation I (480 mins. or 8 hrs. max.)
Psychological Evaluation II (600 mins. or 10 hrs. max.)
All Disciplines
Bonding Study I or II (600 mins. or 10 hrs. max)
Family Psychodynamic Formulation (600 mins. or 10
hrs. max
Attachment Assessment (600 mins. or 10 hrs. max)
Court Report (per report)
Court Testimony (per hour of testimony, Court prep or
wait time)
X9504M
X9504M
X9504M
X9504M
X9504M
CR
CT
Avatar
Service Code
3
3
3
82
85
150
158
159
891
205
127
205
31
31
42
96
96
97
98
99
3CR
3CT
Per Min.
$2.61
$2.61
$2.61
$2.61
$2.61
$2.61
$2.61
$2.61
$2.61
$2.61
$2.61
$2.02
$3.88
$3.88
$4.82
$3.61
$3.61
$2.61
$2.61
$2.61
$ 60.00/report
$ 60.00/report
DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT
I. ldenti in Information
Name of entity D/B/A
Address (number, street) City
CLIA number Taxpayer ID number (EIN) Telephone number
ZIP code
Exhibit H
Page 1 of 2
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.
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? ........................................................................................................................ .
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? .................................................................................... ..
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) .......... .
YES NO
Cl Cl
Cl Cl
Cl Cl
Ill. 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: Cl Sole proprietorship Cl Partnership Cl Corporation
o Unincorporated Associations Cl 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 .......................................................................................................... . Cl 0
NAME ADDRESS PROVIDER NUMBER
IV. A. Has there been a change in ownership or control within the last year? ...................................................... .
If yes, give date. ----------------------------------
B. Do you anticipate any change of ownership or control within the year? ...................................................... .
lfyes,when? ________________________________________ __
C. Do you anticipate filing for bankruptcy within the year? ............................................................................... .
lfyes,when? ________________________________________ __
V. Is the facility operated by a management company or leased in whole or part by another organization? ......... .
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? ........ .
VII. A Is this facility chain affiliated? ..................................................................................................................... .
If es, list name, address of cor oration, and EIN.
Name EIN
Address (number, name) City State
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
ZIP code
Exhibit H
Page 2 of 2
YES NO
Ll Ll
Ll Ll
Ll Ll
Ll Ll
Ll Ll
Ll Ll
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.
CERTIFICATION
Revised Exhibit I
2 of 2
(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:
(Printed Name & Title)
Date:
(Name of Agency or
Company)