The URL can be used to link to this page

Home My WebLink AboutA-15-052 DPH Misc. Docs.pdf co U iI County of Fresno p� s6 p DEPARTMENT OF PUBLIC HEALTH ESQ David Luchini, Director Dr. Rais Vohra, Interim Health Officer July 18, 2022 Office of Legal Affairs University of California, San Francisco 745 Parnassus Ave. San Francisco, CA 944143 Agreement: 15-052 Dear Contractor, The County of Fresno, Department of Public Health has not received current verification of your insurance requirements in accordance with the "Insurance" Section of the Agreement between the County of Fresno and your agency. Please send us an original insurance certificate(s) verifying that your insurance is in compliance for the current period of the Agreement at your earliest possible convenience but no later than thirty (30) days from the date of this letter. Please forward a copy of the certificate to dphcontracts(@-fresnocountyca.gov or mail the original to: County of Fresno, Department of Public Health P.O. Box 11867 Fresno, CA 93775 ATTN: Contracts Section — 6th Floor If you have any questions, please contact me at (559) 600-7090. Sincerely, Roberta Bynum Senior Staff Analyst RB: Iw Promotion,preservation and protection of the community's health 1221 Fulton Street/P.O. Box 11867, Fresno,CA 93775 (559)600-3200 0 FAX(559)600-7687 The County of Fresno is an Equal Employment Opportunity Employer www.co.fresno.ca.us ❑ www.fcdph.org i l co or 0 County of Fresno DEPARTMENT OF PUBLIC HEALTH September 7, 2021 Office of Legal Affairs University of California, San Francisco 745 Parnassus Ave. San Francisco, CA 94143 Agreement: 15-052 Dear Contractor, The County of Fresno, Department of Public Health has not received current verification of your insurance requirements in accordance with the "Insurance" Section of the Agreement between the County of Fresno and your agency. Please send us an original insurance certificate(s) verifying that your insurance is in compliance for the current period of the Agreement at your earliest possible convenience but no later than thirty (30) days from the date of this letter. Please forward a copy of the certificate to dphcontracts(aD_fresnocountyca.gov or mail the original to: County of Fresno, Department of Public Health P.O. Box 11867 Fresno, CA 93775 ATTN: Contracts Section — 6th Floor If you have any questions, please contact me at (559) 600-7090. Sincerely, Roberta Bynum Senior Staff Analyst RB: Iw Promotion,preservation and protection of the community's health 1221 Fulton Street/P. O. Box 11867, Fresno,CA 93775 (559)600-3200 0 FAX(559)600-7687 The County of Fresno is an Equal Employment Opportunity Employer www.co.fresno.ca.us 0 www.fcdph.org co County of Fresno DEPARTMENT OF PUBLIC HEALTH April 30, 2021 Office of Legal Affairs University of California, San Francisco 745 Parnassus Ave. San Francisco, CA 94143 Agreement: 15-052 Dear Contractor, The County of Fresno, Department of Public Health has not received current verification of your insurance requirements in accordance with the "Insurance" Section of the Agreement between the County of Fresno and your agency. Please send us an original insurance certificate(s) verifying that your insurance is in compliance for the current period of the Agreement at your earliest possible convenience but no later than thirty (30) days from the date of this letter. Please forward a copy of the certificate to dphcontracts(@-fresnocountyca.gov or mail the original to: County of Fresno, Department of Public Health P.O. Box 11867 Fresno, CA 93775 ATTN: Contracts Section — 6th Floor If you have any questions, please contact me at (559) 600-7090. Sincerely, � 1 \ � A, 11' i o erta Bynum Senior Staff Analyst RB: Iw Promotion,preservation and protection of the community's health 1221 Fulton Street/P. 0. Box 11867, Fresno,CA 93775 (559)600-3200 0 FAX(559)600-7687 The County of Fresno is an Equal Employment Opportunity Employer www.co.fresno.ca.us 0 www.fcdph.org co CONTRACT STATUS FORM O� s6 O DATE: August 01, 2024 FR DIVISION(S): Children's Medical Services, Community Health, Public Health Nursing (Lead Division listed first) RECEIVED CONTRACTOR: University of California, San Francisco OCT 0 2 2024 SERVICES: Remote Electronic Medical Record Access DEPARTMENT OF PUBLIC HDTH CONTRACTS SECTION CONTRACT TERM: 2/10/15 to 2/10/25 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201600 56201665 56201661 56201650 CONTRACT AMOUNT: $0.00 Contract#: A-15-052 State/Vendor M Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2024 Extend contract through: 120 1-1 With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: FC0alA121 /O , 20 'Z Cancel contract effective: , 20 . Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program SupepAmr/S st: Date: "D r—07 Division Man er: `` Date: ' - Z Submit to: DPH Contracts - Stop#147 - Brix Building, 6th Floor- Phone#: 600-7090 0 e County of Fresno o� s6 o DEPARTMENT OF PUBLIC HEALTH ESQ David Luchini, Director Dr. Rais Vohra, Interim Health Officer September 24, 2024 Office of Legal Affairs University of California, San Francisco 745 Parnassus Ave. San Francisco, CA 944143 Agreement: 15-052 Dear Contractor, The County of Fresno, Department of Public Health has not received current verification of your insurance requirements in accordance with the "Insurance" Section of the Agreement between the County of Fresno and your agency. For your reference the insurance requirements are listed on pages 5 and 6 of the enclosed Agreement. Please send us an original insurance certificate(s) verifying that your insurance is in compliance for the current period of the Agreement at your earliest possible convenience but no later than thirty (30) days from the date of this letter. Please forward a copy of the certificate(s) to dphcontracts(aD-fresnocountyca.gov or mail the original to: County of Fresno, Department of Public Health P.O. Box 11867 Fresno, CA 93775 ATTN: Contracts Section — 6th Floor If you have any questions, please contact me at (559) 600-7090. 'ncerely, R�erta Bynum Senior Staff Analyst RB: Iw Promotion,preservation and protection of the community's health 1221 Fulton Street/P. 0. Box 11867, Fresno,CA 93775 (559)600-3200 0 FAX(559)600-7687 The County of Fresno is an Equal Employment Opportunity Employer www.co.fresno.ca.us 0 www.fcdph.oro CO CONTRACT STATUS FORM fp O� e56 O DATE: August 01, 2023 s, DIVISION(S): Children's Medical Services, Community Health, Public Health Nursing (Lead Division listed first) CONTRACTOR: University of California, San Francisco RECEIVED SERVICES: Remote Electronic Medical Record Access AUG 15 2023 DEPARTMENT OF CaTRACTS�&��H CONTRACT TERM: 2/10/15 to 2/10/24 E ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201600 56201665 56201661 56201650 CONTRACT AMOUNT: $0.00 Contract#: A-15-052 State/Vendor#: Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:November 1. 2023 Extend contract through: „w,�, _, , 20 With no changes in terms or conditions. ❑ With the following change(s): ® Evergreen: Continue contract through: febr 4 �d , 20 -1S ❑ Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by. program Date: Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 _ CO U� CONTRACT STATUS FORM O s56 O DATE: August 01, 2022 DIVISION(S): Children's Medical Services, Community Health, Public Health Nursing (Lead Division listed first) CONTRACTOR: University of California, San Francisco RECEIVE SERVICES: Remote Electronic Medical Record Access SEP282 2 CONTRACT TERM: 2/10/15 to 2/10/23 E DEACON NTOF lJ TION�m ADDITIONAL INFO: Evergreen Agreement-Please Review ORGANIZATION #(s): 56201600 56201665 56201661 56201650 CONTRACT AMOUNT: $0.00 Contract#: A-15-052 State/Vendor#: Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2022 Extend contract through: , 20 ❑ With no changes in terms or conditions. ❑ With the following change(s): n Evergreen: Continue contract through: Febr-UgY'y /� , 20 02 aCancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by. Staff A lyst: '`� Date: 61 Division Manager ' - Date: O� Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 aw No CONTRACT STATUS FORM ti co�,�� O� 56 O DATE: August 02, 2021 s� DIVISION(S): Children's Medical Services, Community Health, Public Health Nursing (Lead Division listed first) CONTRACTOR: University of California, San Francisco SERVICES: Remote Electronic Medical Record Access RECEIVED DEC 17 2021 CONTRACT TERM: 2/10/15 to 2/10/22 E DEPARTMENT OF PUBLIC H LT ADDITIONAL INFO: Evergreen Agreement-Please Review CONTRACTS SECTION ORGANIZATION #(s): 56201600 56201665 56201661 56201650 CONTRACT AMOUNT: $0.00 Contract#: A-15-052 State/Vendor#: Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2021 Extend contract through: , 20 ❑ With no changes in terms or conditions. ❑ With the following change(s): ® Evergreen: Continue contract through: Ftbn40rg /0 , 20 023 ❑ Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by. Program a isor st: Date: Division Manag Date: — Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 coU� C"NTRACT STATUS FO)KM 0 DATE: July 31, 2020ES� DIVISION(S): Children's Medical Services, Community Health, Public Health Nursing (Lead Division listed first) RECEN CONTRACTOR: University of California, San Francisco JAN 2 6 2 21 SERVICES: Remote Electronic Medical Record Access DEPARTMENT OF PUBLI EALTH CONTRACTS SECTION CURRENT PERIOD: 2/10/15 to 2/10/21 E Auto-renewal: ❑ through: (If not checkmarked above,contract will terminate ENTIRE TERM: 2/10/2015 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201600 56201665 56201661 56201650 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Evergreen Agreement-Please Review Contract#: A-15-052 State/Vendor#: Lead Dept: DPH Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2020 Renew contract through: , 20 ❑ With no changes in terms or conditions. 1-1 With the following change(s): Evergreen: Continue contract through: 0 , 20 . Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by. P I st: �C/r1 Gt� / Date: Division Ma ger: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 ti co C"NTRACT STATUS FOWM 0 18s6 0 DATE: July 31, 2019 DIVISION(S): Children's Medical Services, Community He Ith, Public Health Nursing (Lead Division listed first) RCEIVED CONTRACTOR: University of California, San Francisco AUG 21 2019 SERVICES: Remote Electronic Medical Record Acc&WTMENT OF PUBLIC HEALTH CONTRACTS SECTION CURRENT PERIOD: 2/10/15 to 2/10/20 E Auto-renewal: ❑ through: (If not checkmarked above,contract will terminate ENTIRE TERM: 2/10/2015 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201600 56201665 56201661 56201650 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Evergreen Agreement-Please Review Contract#: A-15-052 State/Vendor#: Lead Dept: CMS Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2019 Renew contract through: , 20_ With no changes in terms or conditions. ❑ With the following change(s): B"/Evergreen: Continue contract through: HrUa�! ID , 20 < / Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by.- Program Supervisor/Staff Anal s : • s/ Cpn/S Date: Division Mana er: Date: 20 -1`1 Submit to: DPH Con racts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 CO, C "NTRACT STATUS FOB' M ti; Ofi° s36 O DATE: July 31,2018, DIVISION(S): Children'#Medical Services, Community_Health, h Nursing (Lead Division listed first) " CONtRACTOR: University of California, San Francisco MA R SS EPARTMEN OF SECTip SERVICES: Remote-F-Iectr6nic Medical Record Access p CMENR I CURRENT PERIOD: 2/10/15 to 2/10/2019 E Auto-renewal: ❑ through:',., (If not checkmarked above,contract will terminate ENTIRE-TERM: 2/10/2015 to Evergreen at the end of the current Period.) " F. ORGANIZATION #(s): 56201600 56201618 56201665- 56201661 56201650 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#:'A-15.-052 State/Vendor#: Lead Dept: CMS Other Dept(s) ,..,., Complete the information below: 'and return to DPH Contracts by: November 1 2018 Vn c\ZXnt ct r gh. A1 0 L With no changes in terms or conditions vWith the tollowing c ange s Evergreen: Continue contract through: 20 f ❑ Cancel contract effective: 12 , ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.)-. osier Cap rK#Al �> �c�r� ac�tss. Approved by: Program Supervisor/S Analyst: Date: l�o / Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 co County of Fresno o� 36 o DEPARTMENT OF PUBLIC HEALTH ESQ David Pomaville, Director Dr. Sara Goldgraben, Health Officer October 29, 2018 Office of Legal Affairs University of California, San Francisco 745 Parnassus Ave. San Francisco, CA 94143 Dear Contractor, The County of Fresno, Department of Public Health has not received current verification of your insurance requirements in accordance with the "Insurance" Section of the Agreement between the County of Fresno and your agency. Please send us an original insurance certificate(s) verifying that your insurance is in compliance for the current period of the Agreement at your earliest possible convenience but no later than thirty (30) days from the date of this letter. Please forward a copy of the certificate to dphcontractse-fresnocountyca.gov or mail the original to: County of Fresno, Department of Public Health P.O. Box 11867 Fresno, CA 93775 ATTN: Contracts Section — 6th Floor If you have any questions, please contact me at (559) 600-7090. ncerely, Roberta Bynum Senior Staff Analyst RB: Iw Promotion,preservation and protection of the community's health 1221 Fulton Street, Fresno Ca. 93721/P. 0. Box 11867, Fresno,CA 93775 (559)600-3330 • FAX(559)455-4705 The County of Fresno is an Equal Employment Opportunity Employer www.co.fresno.ca.us • www.fcdoh.ora ti co U� CONTRACT STATUS FQTM 9 fp O� 56 O DATE: July 31, 2018 FxES� DIVISION(S): Children's Medical Services, Community Health, Public Health Nursing (Lead Division listed first) RECEIVED CONTRACTOR: University of California, San Francisco AUG 0 9 2018 SERVICES: Remote Electronic Medical Record Access pEPARTMENTOF PUBLIC HEALTH ONTRACTS SECTION 0FL, CURRENT PERIOD: 2/10/15 to 2/10/2019 E Auto-renewal: through: 2-/6 Zato M►9 (If not chec marked above,contract wil terminate ENTIRE TERM: 2/10/2015 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201600 56201618 56201665 56201661 56201650 CONTRACT AMOUNT: $0.00 ADDITIONAL INFO: Contract#: A-15-052 State/Vendor#: Lead Dept: CMS Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2018 Renew contract through: , 20 ❑ With no changes in terms or conditions. ❑ With the following change(s): Evergreen: Continue contract through: /a 20 7-0 04 tNI ' x Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff Anal y t: Date: �( Division Ma Date: :21 (� Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 CO, O U� CUNTRACT STATUS FORM ti O� 56 O DATE: August 01, 2017 FRESH DIVISION(S): Children's Medical Services, Community Health,�ubli ealth Nursing (Lead Division listed first) • �CEIVED CONTRACTOR: University of California, San Francisco AUG 0 3 2017 SERVICES: Remote Electronic Medical Record Access DEPARTMENT O SpUBUCHEALN CONTRASECTION CURRENT PERIOD: 2/10/17 to 2/10/2018 E Auto-renewal: W through: (If not checkmarked above,contract will terminate ENTIRE TERM: 2/10/2015 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201600 56201618 56201665 56201661 56201650 CONTRACT AMOUNT $0.00 ADDITIONAL INFO: CMS is lead Division, no contractor information was included in Agreement Contract#: A-15-052 State/Vendor#: Lead Dept: CMS Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2017 jr—R�� tract through: E j 10 , 20 With no changes i onditions. I h the following change(s): Evergreen: Continue contract through: b 20 1 . Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: ` Program Supervisor/Staff Analyst: v Date: 1-7 's Division Manager: Date: Z Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 U� CONTRACT STATUS FORM ti CO DATE: August 01, 2016ES� DIVISION(S): Children's Medical Services, Community Health, Public Health Nursing (Lead Division listed first) RECEIVED CONTRACTOR: University of California, San Francisco SEP 2 8 Z016 SERVICES: Remote Electronic Medical Record Access DEPARTMENT OF PUBLIC HEk CONTRACTS SECTION CURRENT PERIOD: 2/10/16 to 2/10/17 E Auto-renewal: f 1 through: (If not checkmarked above,contract will terminate ENTIRE TERM: 2/10/2015 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201600 56201618 56201665 56201661 56201650 CONTRACT AMOUNT $0.00 ADDITIONAL INFO: CMS is lead Division, no contractor information was included in Agreement Contract#: A-15-052 State/Vendor M Lead Dept: CMS Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2016 Renew contract through: , 20 ❑ With no changes in terms or conditions. With the following change(s): Evergreen: Continue contract through: (� 20 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): 1 S_ Approved by: S Program Supervisor/S Analy �`- Date: Ira J/z- Division Manager: Date:"' Z/ 11h W Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 CIO CONTRACT STATUS FORM d '� DATE: August 01, 2016 FRESH DIVISION(S): Children's Medical Services, Community Health, LtIV Nursing (Lead Division listed first) C'V C u CONTRACTOR: University of California, San Francisco AUG 0 4 2016 SERVICES: Remote Electronic Medical Record Access DEPARTMENT OF PUBLIC H THY CONTRACTS SECTION CURRENT PERIOD: 2/10/16 to 2/10/17 E Auto-renewalAthe through: �6 (If not therked above,contract wil term ate ENTIRE TERM: 2/10/2015 to Evergreen aend of the current period.) ORGANIZATION #(s): 56201600 56201618 56201665 56201661 56201650 CONTRACT AMOUNT $0.00 ADDITIONAL INFO: CMS is lead Division, no contractor information was included in Agreement Contract#: A-15-052 StateNendor#: Lead Dept: CMS Other Dept(s): Complete the information below and return to DPH Contracts by:November 1,r 2016 Renew contract through: , CI?%--> 2— ") , 20 C> FWith no changes in terms or conditions. 1-1 With the following change(s): Evergreen: Continue contract through: 20 ❑ Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff st: Date: Division Manager: - Date: 3 �/ Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 0 i Department of Public Health AGREEMENT/AMENDMENT ADMINISTRATION NOTIFICATION FORM Please complete this form, attach executed Agreement, forward to: DPH CONTRACTS - 6th Floor - Stop #147 [Name of Contractor: TUICSF Services Provided: Electronic Medical Record Access Contract Term: Until written notice is given Org #(s): 56201600, 56201618, 5620/665, 5620661 Division(s): CMS, PHN, CH 56 zo 165o Account #: N/A Other Departments: Revenue Agreement: yes: ❑ no: �x Total Compensation: Type of Agreement: Board: ❑x Purchasing: ❑ Inter-Departmental NEW Agreement: yes: ❑x no: ❑ Amendment: yes: ❑ no: ❑x Completed by: -�-� ( 3 a S Sign ture/Title Date RECEIVED MAR 1 0 2015 DEPARTMENT OF PUBLIC HEALTH CONTRACTS SECTION IMPCO U� C(5NTRACT STATUS FORM O� 56 O DATE: August 03, 2015ES� DIVISION(S): Children's Medical Services, Commuinity Health, Public Health Nursing (Lead Division listed first) CONTRACTOR: University of California, San Francisco SERVICES: remote electronic medical record access CURRENT PERIOD: 2/10/15 to 2/10/16 E Auto-renewal: O through: (if not checkmarked above,contract will terminate ENTIRE TERM: 2/10/2015 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201600 56201618 56201665 56201661 56201650 CONTRACT AMOUNT $0.00 ADDITIONAL INFO: CMS is lead Division, no contractor information was included in Agreement Contract#: A-15-052 State/Vendor M Lead Dept: CMS Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2015 Renew contract through: , 20 With no changes in terms or conditions. ❑ With the following change(s): Evergreen: Continue contract through: FE �R� ) , 20 / 7 Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: ram Supervisor/Staff Analyst: �� r��r�- Date: vision Man Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor - Phone #: 600-7090 w coU� CONTRACT STATUS FORM O� 56 O DATE: August 03, 2015 Est DIVISION(S): Children's Medical Services, Commuinity Health, Public Health Nursing (Lead Division listed first) CONTRACTOR: University of California, San Francisco SERVICES: remote electronic medical record access CURRENT PERIOD: 2/10/15 to 2/10/16 E Auto-renewal: V through: (If not checkmarked above,contract will terminate ENTIRE TERM: 2/10/2015 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201600 56201618 2016 6201661 6201650 CONTRACT AMOUNT $0.00 ADDITIONAL INFO: CMS is lead Division, no contractor information was included in Agreement Contract#: A-15-052 State/Vendor M Lead Dept: CMS Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2015 Renew contract through: 20 RECEIVED AUG 0 4 2015 ❑ With no changes in terms or conditions. DEPARTMENT OF PUBLIC HEALTH CONTRACTS SECTION With the following change(s): J?'Evergreen: Continue contract through: E 1 \p , 20 \21 , Cancel contract effective: , 20 Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/Staff Analysts Dater,,", Division Manager: Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090 coU� C 'kTRACT STATUS FORM DATE: August 03, 2015 DIVISION(S): Children's Medical Services, Commuinity Health,Rublic Health Nursing (Lead Division listed first) CONTRACTOR: University of California, San Francisco SERVICES: remote electronic medical record access CURRENT PERIOD: 2/10/15 to 2/10/16 E Auto-renewal: C, through: (If not checkmarked above,contract will terminate ENTIRE TERM: 2/10/2015 to Evergreen at the end of the current period.) ORGANIZATION #(s): 56201600 56201618 56201665 56201661 56201650 CONTRACT AMOUNT $0.00 ADDITIONAL INFO: CMS is lead Division, no contractor information was included in Agreement Contract#: A-15-052 State/Vendor M Lead Dept: CMS Other Dept(s): Complete the information below and return to DPH Contracts by:November 1, 2015 Renew contract through: With no changes in terms or conditions. With the following change(s): ❑ Evergreen: Continue contract through: 20 ❑ Cancel contract effective: , 20 ❑ Additional Information (e.g., anticipated effective date/term, contract extension, etc.): Approved by: Program Supervisor/ Analys Date:/d Zg o Division Manager: 1��tAM� Date: Submit to: DPH Contracts - Stop #147 - Brix Building, 6th Floor- Phone #: 600-7090