114161-O4.pdf

DHHS Fee for Service Contract Page 1 of 9 Rev. 09/2019

INTERPRETATION/TRANSLATION SERVICE CONTRACT

BETWEEN

THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES

AND

This contract, including any attachments (collectively, “Contract”) is entered into by and between the Nebraska Department of Health and Human Services, __________________________ (hereinafter “DHHS”), and _____________________________ (hereinafter “Contractor”).

PURPOSE: The purpose of this Contract is to provide language translation and/or interpretation services for DHHS. These services may include translation and/or interpretation for or on behalf of DHHS program clients and/or providers (hereinafter collectively “clients”).

FUNDING: This Contract involves _________________

MEDICAID: This Contract _____________ Medicaid funds.

1. DURATION

1.1. TERM. This agreement begins on the later of ________________ or the date this agreement is signed by the parties. This agreement ends on ________________.

2. PAYMENT TERMS AND STRUCTURE

2.1. TOTAL PAYMENT. DHHS shall pay Contractor $________ per hour for services provided herein, in a total amount not to exceed $500.00 (five hundred dollars).

2.2. INVOICING. Upon completion of all services, Contractor shall invoice DHHS for all fees. DHHS shall pay consistent with the terms provided herein.

2.2.1. The Contractor shall ensure at minimum the following information is on each billing document:

2.2.1.1. Date of Invoice;

2.2.1.2. Contract Number

2.2.1.3. The Contractor’s name, language, address and phone number;

2.2.1.4. The name of the referring DHHS staff person or Authorized Representative, phone number, office location and division of the referring DHHS staff person;

2.2.1.5. The DHHS client name, client ID number, address and phone number, or the event and/or group assisted with interpretation and/or translation services;

2.2.1.6. The date(s) that interpretation and/or translation services were provided to DHHS or the client;

2.2.1.7. The start time and end time that direct interpretation and/or translation services were provided;

2.2.1.8. The total number of billable hours that interpretation and/or translation services were provided for each scheduled in-person or telephonic session;

2.2.1.9. The type of interpretation and/or translation services provided (in-person face-to-face, telephonic, written material only);

2.2.1.10. The total amount due; and

2.2.1.11. The Contractor’s signature, printed name, and date of signature.

2.2.2. The Contractor shall submit a billing document by no later than the sixtieth (60th) calendar day following the month the service was completed. If this day falls on a weekend or holiday, the Contractor shall submit the billing document on or before the next business day. DHHS reserves the right to refuse payment for any initial request that is submitted later than the deadline set herein.

Docusign Envelope ID: 2D3282C1-A710-4B3B-AB2A-48A0921771AB

50.00

12-15-25

Kham Noam Nang

Kham Noam Nang

12-31-25 state funds

Does Not Use

Division of Behavioral Health

DHHS Fee for Service Contract Page 2 of 9

2.2.3. The Contractor is responsible for any and all costs associated with the production and delivery of services and billing documents.

2.2.4. Any term included in Contractor’s invoice shall be deemed to be solely for the convenience of the parties. No payment shall be made for any deliverable or cost unless specifically authorized in the terms of the Contract.

2.3. PROMPT PAYMENT. Payment shall be made in compliance with the Nebraska Prompt Payment Act, Neb. Rev. Stat. §§ 81-2401 et seq. DHHS shall make payment in full for services provided on or before the forty-fifth (45th) calendar day after (a) the date of the completion of the service(s) or (b) the date of receipt by DHHS of the invoice for the service(s), whichever is later. Payment shall be made by electronic means. The Contractor shall complete and sign the State of Nebraska ACH Enrollment Form and obtain the necessary information and signatures from their financial institution. The completed form must be submitted before payments may be made.

Download ACH Form: http://das.nebraska.gov/accounting/nis/address_book_info.htm

3. SERVICES PROVIDED

3.1. DESCRIPTION OF SERVICES. The Contractor shall do the following:

3.1.1. Provide proficient, clear, and accurate verbal and written translation and/or interpretation services from English into language which Contractor is proficient and from said language[s] into English. All translation and interpretation shall be as exact as possible, and include translation and/or interpretation of verbal questions, answers, and statements made by anyone present or involved in conversations with DHHS and clients.

3.1.1.1. Translation and interpretation services shall also follow all requirements set forth in

Attachments A and B; and

3.1.1.2. Said services must be provided in accordance with all applicable state and federal laws, including but not limited to: Title VI of the Civil Rights Act of 1964, 42 U.S.C.

§§ 2000d et seq.; the Americans with Disabilities Act, 42 U.S.C. 12101 et seq.; the Rehabilitation Act of 1973, 29 U.S.C. §§ 794 et seq.; Executive Order 13166; and all policy guidelines from the Office of Civil Rights.

3.1.2. Be physically present to provide translation and/or interpretation, unless DHHS specifically requests otherwise.

3.1.2.1. Contractor shall travel to a location designated by DHHS to provide face-to-face interpretation and/or translation, including but not limited to DHHS offices and 24-hour facilities, provider offices, or the homes of clients.

3.1.2.2. Verbal interpretation services not provided in person shall be provided via conference telephone.

3.1.3. If written translation is requested by DHHS, provide written translation of another language in a format specified by DHHS.

3.1.4. Keep all communications made in performance of the interpretation and/or translation services under this contract confidential, as set forth herein and in Attachments A and B. All protected health information of any client or client shall be accorded the proper safeguards as provided in Attachments A, B, and C.

3.1.5. If a license or certification is required by law to provide translation or interpretation services, maintain said license or certification throughout the term of this contract.

3.1.5.1. Should Contractor lose such required certification at any time during the term of this contract, DHHS may immediately terminate this contract;

3.1.5.2. No payments shall be made by DHHS for any services performed by Contractor without a required current license or certification; and

3.1.5.3. If Contractor is translating or interpreting from English to American Sign Language

(hereinafter “ASL”), or from ASL to English, the duties set forth in this subsection include, but are not limited to, the legal requirements for ASL Interpretation in Nebraska, and those set by the Nebraska Commission for the Deaf and Hard of Hearing for licensure.

3.1.5.4. Contractor shall not commence work under this contract until all license or certification required hereunder has been provided to DHHS.

Docusign Envelope ID: 2D3282C1-A710-4B3B-AB2A-48A0921771AB http://das.nebraska.gov/accounting/nis/address_book_info.htm

DHHS Fee for Service Contract Page 3 of 9

4. GENERAL TERMS

4.1. ACCESS TO RECORDS. All Contractor books, records, and documents, regardless of physical form, including data maintained in computer files or on magnetic, optical or other media, relating to work performed or monies received under this Contract, shall be subject to audit by DHHS or its authorized representative at any reasonable time and upon the provision of reasonable notice. Contractor shall maintain all records for five (5) years from the date of final payment.

4.2. AMENDMENT. This Contract may only be modified by written amendment, executed by both parties.

No alteration or variation of the terms of this Contract shall be valid unless made in writing and signed by the parties.

4.3. CIVIL RIGHTS AND EQUAL OPPORTUNITY EMPLOYMENT. The Parties shall comply with all applicable local, state and federal law regarding civil rights, including but not limited to the Nebraska Fair Employment Practice Act, Neb. Rev. Stat. §§ 48-1101 to 48-1125.

4.4. COMPLIANCE WITH LAW. The Parties shall comply with all other applicable federal, state, county and municipal laws, ordinances, and rules and regulations in the performance of this Contract.

4.5. CONFIDENTIALITY. Any and all information gathered in the performance of this Contract, either independently or through DHHS, shall be held in the strictest confidence and shall be released to no one other than DHHS without the prior written authorization of DHHS. Contrary provisions set forth in the Contract shall be deemed to be authorized exceptions to this general confidentiality provision.

4.6. DRUG-FREE WORKPLACE. Contractor certifies that it maintains a drug-free workplace environment to ensure worker safety and workplace integrity. Contractor shall provide a copy of its drug-free workplace policy at any time upon request by DHHS.

4.7. FORCE MAJEURE. Neither party shall be liable for any costs or damages resulting from its inability to perform any of its obligations under this Contract due to a natural disaster, or other similar event outside the control and not the fault of the affected party.

4.8. INDEMNIFICATION. Contractor shall defend, indemnify, hold, and save harmless DHHS and its employees, volunteers, agents, and its elected and appointed officials (“the indemnified parties”) from and against any and all claims, liens, demands, damages, liability, actions, causes of action, losses, judgments, costs, and expenses of every nature, including investigation costs and expenses, settlement costs, and attorney fees and expenses (“the claims”), sustained or asserted against DHHS, arising out of, resulting from, or attributable to the willful misconduct, negligence, error, or omission of Contractor, except to the extent such Contractor liability is attenuated by any action of the DHHS that directly and proximately contributed to the claims. DHHS’s liability is limited to the extent provided by the Nebraska Tort Claims Act, the Nebraska Contract Claims Act, the Nebraska Miscellaneous Claims Act, and any other applicable provisions of law. DHHS does not assume liability for the action of its contractors.

4.9. INDEPENDENT CONTRACTOR. It is mutually understood and agreed by the Parties that the Contractor is an independent contractor. Contractor will be responsible for the payment of any taxes or fees due because of payment for the service(s).

4.10. INTEGRATION. This written Contract, along with any attachments, represents the entire agreement between the parties, and any prior or contemporaneous representations, promises, or statements by the parties, which are not incorporated herein, shall not serve to vary or contradict the terms set forth in this Contract.

4.11. NEBRASKA NONRESIDENT INCOME TAX WITHHOLDING. Contractor acknowledges that Nebraska law requires DHHS to withhold Nebraska income tax if payments for personal services are made in excess of six hundred dollars ($600) to any contractor who is not domiciled in Nebraska or has not maintained a permanent place of business or residence in Nebraska for a period of at least six months. This provision applies to individuals, to a corporation if 80% or more of the voting stock of the corporation is held by the shareholders who are performing personal services, and to a partnership or limited liability company if 80% or more of the capital interest or profits interest of the partnership or limited liability company is held by the partners or members who are performing personal services.

4.11.1. The parties agree, when applicable, to properly complete the Nebraska Department of

Revenue Nebraska Withholding Certificate for Nonresident Individuals Form W-4NA or its successor. The form is available at: http://www.revenue.nebraska.gov/tax/current/fill-in/f_w4na.pdf

4.12. NEW EMPLOYEE WORK ELGIBILITY STATUS. Contractor shall use a federal immigration verification system to determine the work eligibility status of new employees physically performing

Docusign Envelope ID: 2D3282C1-A710-4B3B-AB2A-48A0921771AB http://www.revenue.nebraska.gov/tax/current/fill-in/f_w4na.pdf http://www.revenue.nebraska.gov/tax/current/fill-in/f_w4na.pdf

DHHS Fee for Service Contract Page 4 of 9 services within the State of Nebraska. A federal immigration verification system means the electronic verification of the work authorization program authorized by the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, 8 U.S.C. § 1324a, known as the E-Verify Program, or an equivalent federal program designated by the United States Department of Homeland Security or other federal agency authorized to verify the work eligibility status of a newly hired employee.

4.12.1. If Contractor is an individual or sole proprietorship, the following applies:

Contractor must complete the United States Citizenship Attestation Form, available on the Department of Administrative Services website at www.das.state.ne.us.

If Contractor indicates on such attestation form that he or she is a qualified alien, Contractor agrees to provide the US Citizenship and Immigration Services documentation required to verify Contractor’s lawful presence in the United States using the Systematic Alien Verification for Entitlements Program.

Contractor understands and agrees that lawful presence in the United States is required and Contractor may be disqualified or the Contract terminated if such lawful presence cannot be verified as required by Neb. Rev. Stat. § 4-108.

4.13. SEVERABILITY. If any term or condition of this Contract is declared by a court of competent jurisdiction to be illegal or in conflict with any law, the validity of the remaining terms shall not be affected, and the rights and obligations of the parties shall be construed and enforced as if this Contract did not contain the particular provision held to be invalid.

4.14. TERMINATION. DHHS and Contractor reserve the right to terminate this Contract at any time. Either party may terminate this Contract for convenience upon 10 (ten) days prior written notice to the other party. DHHS may terminate the Contract, in whole or in part, if Contractor fails to perform its obligations under the Contract in a timely and proper manner.

5. INSURANCE REQUIRED

5.1. The Contractor must possess a valid driver’s license if the Contractor drives to or from any location to provide services under this contract. If the Contractor does drive to or from any location to provide services under this contract, the Contractor shall carry auto liability insurance which, at a minimum, conforms to the statutory minimums as required by Nebraska law; and

5.2. The Contractor shall not commence work under this contract until all the insurance required hereunder has been obtained. The Contractor shall maintain required insurance for the life of this contract.

6. CONTACT INFORMATION

DHHS Contract Manager Contractor

7. ACKNOWLEDGEMENT

By signing below, Contractor certifies, acknowledges and agrees with the following statement:

I acknowledge and agree that I am an independent contractor. I further certify that I am not a current employee of the State of Nebraska. With this Contract, the State of Nebraska, Department of Health and Human Services, is not hiring me as a temporary, part-time, or permanent employee. I hereby waive any current or future claim to employment, employee protections under contract, rule or regulation, healthcare benefits, retirement, or other benefits offered now or in the future by the State of Nebraska.

8. ATTACHMENTS

A. No Medicaid Funds

Docusign Envelope ID: 2D3282C1-A710-4B3B-AB2A-48A0921771AB

801 W Prospector Place

402 429-4467 marilyn.bailey@nebraska.gov

Lincoln, NE 68522

Marilyn Bailey

4027707256

Lincoln NE 68505 430 N 75th Street

Kham Noam Nang khamnoam@hotmail.com http://www.das.state.ne.us/

DHHS Fee for Service Contract Page 5 of 9

B. Medicaid Funds C. DHHS HIPAA Business Associate Agreement

IN WITNESS THEREOF, the parties have duly executed this Contract hereto, and that the individual signing below has authority to legally bind the party to this Contract.

FOR DHHS: FOR CONTRACTOR:

Department of Health and Human Services

DATE: ____________________ DATE: __________________

Kham Noam Nang

Ms kham Nang

8/18/2025 | 18:17:10 CDT

Hospital Administrator

Mitchell Bruening

8/19/2025 | 13:51:32 CDT

DHHS Fee for Service Contract Page 6 of 9

Attachment A Service Attachment – No Medicaid Funds

Effective January 1, 2020

The terms outlined in Service Attachment A apply to the following Divisions of DHHS:

Behavioral Health, Children and Family Services, Operations, Public Health.

The terms outlined in Service Attachment A apply to the Division of Developmental Disabilities when

Medicaid funds are not expended.

DHHS shall pay the Contractor a rate specified in section 2.1.

A. Interpretation and/or Translation Services

1. DHHS shall pay the Contractor an amount equal to one (1) hour’s worth of service if the total translation and/or interpretation services provided by the Contractor for a given scheduled translation and/or interpretation session are equal to or less than one hour in length. For ASL interpretation, any time spent in excess of one hour shall be calculated as set forth in the contract;

2. For ASL interpretation, DHHS shall pay the Contractor an amount equal to two (2) hours’ worth of service if the total translation and/or interpretation services provided by the Contractor for a given scheduled translation and/or interpretation session are equal to or less than one hour in length.

Any time spent in excess of one hour shall be calculated as set forth in the contract;

3. Payment for interpretation and/or translation services includes compensation for the time spent waiting for DHHS staff, clients, participants or providers to begin interpreting and/or translating services, measured from the scheduled time set by DHHS for the interpretation and/or translation services to begin.

4. For telephonic interpretation DHHS shall pay the Contractor a rate per minute for the first one through thirty (1-30) minutes. Any time spent in excess of thirty (30) minutes for over the phone interpretation shall be billed at the hourly rate.

B. Cancellation

1. If DHHS cancels a scheduled in-person or telephonic translation or interpretation session less than twenty-four (24) hours before the scheduled in-person or telephonic translation or interpretation session is set to begin, DHHS shall pay the Contractor a fee equal to one (1) hour of translation and interpretation time to remunerate the Contractor for planning and scheduling work. This same provision shall apply if the cancellation was the result of a cancellation by a participant, or if the participant fails to show at the scheduled in-person or telephonic translation or interpretation session;

2. If DHHS cancels a scheduled in-person or telephonic translation or interpretation session more than twenty-four (24) hours before the scheduled in-person or telephonic translation or interpretation session is set to begin, Contractor shall not receive any payment; and

3. If the Contractor cancels a scheduled in-person or telephonic translation or interpretation session, DHHS shall owe no payment.

C. Applicability

1. All provisions in this Service Attachment apply to services provided for all divisions of the

Department of Health and Human Services and to its participants, except services provided to or on behalf of the Division of Medicaid and Long Term Care and its participants.

2. Nothing in this Service Attachment shall be construed to conflict with any state or federal legal requirement based on the type of funds being used or services provided.

DHHS Fee for Service Contract Page 7 of 9

Attachment B

Service Attachment – Medicaid Funds Effective January 1, 2020

The terms outlined in Service Attachment B apply to the Division of Medicaid and Long Term Care.

The terms outlined in Service Attachment B apply to the Division of Developmental Disabilities when

Medicaid funds are expended.

DHHS shall pay the Contractor a rate specified in section 2.1.

A. Cancellation

1. DHHS may cancel a scheduled in-person or telephonic interpretation and/or translation session at any time without penalty. This same provision applies if a participant fails to appear for a scheduled in-person or telephonic translation and/or interpretation session.

B. Applicability

1. All provisions in this Service Attachment apply to services provided to or on behalf of the Division of Medicaid and Long Term Care and its participants.

D. Medicaid Privacy Rules

1. Contractor shall follow all Medicaid privacy rules at 42 CFR Part 431, Subpart F. Contractor must not disclose to others the name, contact information, medical condition, or any other personally identifiable information about any Medicaid recipient.

DHHS Fee for Service Contract Page 8 of 9

ATTACHMENT C

DHHS HIPAA BUSINESS ASSOCIATE AGREEMENT PROVISIONS

1. BUSINESS ASSOCIATE. “Business Associate” shall generally have the same meaning as the term

“business associate” at 45 CFR § 160.103, and in reference to the party in this Contract, shall mean Contractor.

2. COVERED ENTITY. “Covered Entity” shall generally have the same meaning as the term “covered entity” at 45 CFR § 160.103, and in reference to the party to this Contract, shall mean DHHS.

3. HIPAA RULES. “HIPAA Rules” shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Part 160 and Part 164.

4. OTHER TERMS. The following terms shall have the same meaning as those terms in the HIPAA Rules:

Breach, Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, Protected Health Information, Required by Law, Secretary, Security Incident, Subcontractor, Unsecured Protected Health Information, and Use.

5. THE CONTRACTOR shall do the following:

5.1. Not use or disclose Protected Health Information other than as permitted or required by this Contract or as required by law. Contractor may use Protected Health Information for the purposes of managing its internal business processes relating to its functions and performance under this Contract. Use or disclosure must be consistent with DHHS’ minimum necessary policies and procedures.

5.2. Implement and maintain appropriate administrative, physical, and technical safeguards to prevent access to and the unauthorized use and disclosure of Protected Health Information. Comply with Subpart C of 45 CFR Part 164 with respect to electronic Protected Health Information, to prevent use or disclosure of Protected Health Information other than as provided for in this Contract and assess potential risks and vulnerabilities to the individual health data in its care and custody and develop, implement, and maintain reasonable security measures.

5.3. To the extent Contractor is to carry out one or more of the DHHS’ obligations under Subpart E of 45 CFR Part 164, comply with the requirements of Subpart E that apply to DHHS in the performance of such obligations. Contractor may not use or disclosure Protected Health Information in a manner that would violate Subpart E of 45 CFR Part 164 if done by DHHS.

5.4. In accordance with 45 CFR §§ 164.502(E)(1)(ii) and 164.308(b)(2), if applicable, ensure that any agents and subcontractors that create, receive, maintain, or transmit Protected Health Information received from DHHS, or created by or received from the Contractor on behalf of DHHS, agree in writing to the same restrictions, conditions, and requirements relating to the confidentiality, care, custody, and minimum use of Protected Health Information that apply to the Contractor with respect to such information.

5.5. Obtain reasonable assurances from the person to whom the information is disclosed that the information will remain confidential and used or further disclosed only as required by law or for the purposes for which it was disclosed to the person, and the person notifies the Contractor of any instances of which it is aware that the confidentiality of the information has been breached.

5.6. Within fifteen (15) days:

5.6.1. Make available Protected Health Information to DHHS as necessary to satisfy DHHS’ obligations under 45 CFR § 164.524;

5.6.2. Make any amendment(s) to Protected Health Information as directed or agreed to by DHHS pursuant to 45 CFR § 164.526, or take other measures as necessary to satisfy DHHS’ obligations under 45 CFR § 164.526;

5.6.3. Maintain and make available the information required to provide an accounting of disclosures to DHHS as necessary to satisfy DHHS’ obligations under 45 CFR § 164.528.

5.7. Make its internal practices, books, and records relating to the use and disclosure of Protected Heath Information received from, or created or received by the Contractor on behalf of the DHHS available to the Secretary for purposes of determining compliance with the HIPAA rules. Contractor shall provide DHHS with copies of the information it has made available to the Secretary.

5.8. Report to DHHS within fifteen (15) days, any unauthorized use or disclosure of Protected Health

DHHS Fee for Service Contract Page 9 of 9

Information made in violation of this Contract, or the HIPAA rules, including any security incident that may put electronic Protected Health Information at risk. Contractor shall, as instructed by DHHS, take immediate steps to mitigate any harmful effect of such unauthorized disclosure of Protected Health Information pursuant to the conditions of this Contract through the preparation and completion of a written Corrective Action Plan subject to the review and approval by DHHS. The Contractor shall report any breach to the individuals affected and to the Secretary as required by the HIPAA rules.

6. TERMINATION.

6.1. DHHS may immediately terminate this Contract and any and all associated contracts if DHHS determines that the Contractor has violated a material term of this Contract.

6.2. Within thirty (30) days of expiration or termination of this Contract, or as agreed, unless Contractor requests and DHHS authorizes a longer period of time, Contractor shall return or at the written direction of DHHS destroy all Protected Health Information received from DHHS (or created or received by Contractor on behalf of DHHS) that Contractor still maintains in any form and retain no copies of such Protected Health Information. Contractor shall provide a written certification to DHHS that all such Protected Health Information has been returned or destroyed (if so instructed), whichever is deemed appropriate. If such return or destruction is determined by the DHHS be infeasible, Contractor shall use such Protected Health Information only for purposes that makes such return or destruction infeasible and the provisions of this Contract shall survive with respect to such Protected Health Information.

6.3. The obligations of the Contractor under the Termination Section shall survive the termination of this Contract.

Total Hour Payment: $

Translation: Total Hours

Phone: Total Minutes

START FINISH **SUB-TOTAL HOURS

In Person: Total Service Hours

In Person: Amount to be paid $

Approving Worker's Printed Name and Division

Provider's Printed Name Provider's Phone Number

Date of Signature

Approving Worker's Signature

Total Invoice Payment Amount $

The completed billing document should be submitted to the DHHS Interpreter Billing Email Address at: dhhs.interpreterbilling@nebraska.gov.

DHHS reserves the right to not pay any initial request for payment that is submitted later than sixty (60) calendar days past the last day of the month for which services were provided.

Instructions: Date of Signature

*Please identify whether the interpreting included in-person, over phone, and/or translation services.

**Please round total service hours to the nearest quarter hour except where not allowed per contract (medicaid funds and/or over phone).

Worker's Phone Number

Statement:

By signing this form, the signor certifies that the information contained in this document is true, complete and accurate, and in compliance with the terms of the contract. Anyone filing a false claim may be prosecuted for fraud.

Provider's Signature

$Phone: Amount to be paid

Translation: Amount to be paid $

Date:

ATTACHMENT 5

INTERPRETER BILLING DOCUMENT

Department of Health and Human Services

Interpreter Language:

Interpreter Name:

Interpreter Phone Number:

Interpreter Street Address:

DATE

DHHS Staff Name or Authorized Representative:

DHHS Staff Name or Auth Rep Phone Number:

DHHS Office Location:

DHHS Division:

CASE INFORMATION

Client Name: Client Street Address:

Client ID Number:

Client Phone Number:

SERVICE DELIVERY TIME

Certificate Of Completion Envelope Id: 2D3282C1-A710-4B3B-AB2A-48A0921771AB Status: Completed

Subject: Please DocuSign: Interpretation/Translation Service Contract

Envelope Type: Contract

Envelope Name:

Divison:

DHHS Sender:

DHHS Sharepoint ID:

FFATA Reporting Required:

Source Envelope:

Document Pages: 10 Signatures: 2 Envelope Originator:

Certificate Pages: 5 Initials: 0 Procurement Shared

AutoNav: Enabled

EnvelopeId Stamping: Enabled

Time Zone: (UTC-06:00) Central Time (US & Canada)

301 Centennial Mall S

Lincoln, NE 68508-2529 dhhs.procurement@nebraska.gov

IP Address: 164.119.5.182

Record Tracking Status: Original

8/18/2025 2:52:33 PM

Holder: Procurement Shared dhhs.procurement@nebraska.gov

Location: DocuSign

Security Appliance Status: Connected Pool: StateLocal

Storage Appliance Status: Connected Pool: Nebraska Department of Health & Human

Services

Location: Docusign

Signer Events Signature Timestamp Marilyn Bailey marilyn.bailey@nebraska.gov

Security Level:

DocuSign.email

ID: 1

8/18/2025 2:52:35 PM

Completed

Using IP Address: 164.119.5.182

Sent: 8/18/2025 2:52:35 PM

Viewed: 8/18/2025 2:52:39 PM

Signed: 8/18/2025 2:53:26 PM

Electronic Record and Signature Disclosure:

Accepted: 8/17/2021 1:08:43 PM ID: 4b0e1ae6-3bdc-4641-968e-4b70d6f83b97

Kham Noam Nang khamnoam@hotmail.com

Ms kham Nang

Security Level: Email, Account Authentication (None)

Signature Adoption: Drawn on Device

Using IP Address:

2600:1014:b10b:2f94:8472:950b:bfd7:461f

Signed using mobile

Sent: 8/18/2025 2:53:29 PM

Viewed: 8/18/2025 6:16:05 PM

Signed: 8/18/2025 6:17:10 PM

Electronic Record and Signature Disclosure:

Accepted: 8/18/2025 6:16:05 PM ID: fdb1ee9a-7d62-4988-9b2f-11cdbd9e4bb1

Mitchell Bruening mitchell.bruening@nebraska.gov

Hospital Administrator

Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style

Using IP Address: 164.119.5.90

Sent: 8/18/2025 6:17:12 PM

Viewed: 8/19/2025 1:51:23 PM

Signed: 8/19/2025 1:51:32 PM

Electronic Record and Signature Disclosure:

Accepted: 12/8/2023 2:43:01 PM ID: ae64d5bc-3f4f-45ff-a565-efd358377fd3

In Person Signer Events Signature Timestamp

Editor Delivery Events Status Timestamp

Agent Delivery Events Status Timestamp

Intermediary Delivery Events Status Timestamp

Certified Delivery Events Status Timestamp

Carbon Copy Events Status Timestamp Marilyn Bailey marilyn.bailey@nebraska.gov

Security Level: Email, Account Authentication (None)

Sent: 8/18/2025 2:53:28 PM

Viewed: 8/20/2025 6:51:15 AM

Electronic Record and Signature Disclosure:

Accepted: 5/2/2024 10:04:30 AM ID: 1c6b9951-6b93-4e84-a894-f385dca4057e

Procurement Shared dhhs.procurement@nebraska.gov

DHHS

Security Level: Email, Account Authentication (None)

Sent: 8/19/2025 1:51:35 PM

Resent: 8/19/2025 1:51:41 PM

Viewed: 9/18/2025 1:40:42 PM

Electronic Record and Signature Disclosure:

Not Offered via Docusign

DHHS Interpreter Contracts dhhs.interpretercontracts@nebraska.gov

Security Level: Email, Account Authentication (None)

Sent: 8/19/2025 1:51:37 PM

Electronic Record and Signature Disclosure:

Not Offered via Docusign

Witness Events Signature Timestamp

Notary Events Signature Timestamp

Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 8/18/2025 2:52:35 PM

Certified Delivered Security Checked 8/19/2025 1:51:23 PM

Signing Complete Security Checked 8/19/2025 1:51:32 PM

Completed Security Checked 8/19/2025 1:51:37 PM

Payment Events Status Timestamps

Electronic Record and Signature Disclosure

CONSUMER DISCLOSURE

From time to time, Nebraska Department of Health & Human Services (we, us or Company) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the DocuSign, Inc. (DocuSign) electronic signing system. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to these terms and conditions, please confirm your agreement by clicking the ‘I agree’ button at the bottom of this document.

Getting paper copies At any time, you may request from us a paper copy of any record provided or made available electronically to you by us. You will have the ability to download and print documents we send to you through the DocuSign system during and immediately after signing session and, if you elect to create a DocuSign signer account, you may access them for a limited period of time

(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to send you paper copies of any such documents from our office to you, you will be charged a

$0.00 per-page fee. You may request delivery of such paper copies from us by following the procedure described below.

Withdrawing your consent If you decide to receive notices and disclosures from us electronically, you may at any time change your mind and tell us that thereafter you want to receive required notices and disclosures only in paper format. How you must inform us of your decision to receive future notices and disclosure in paper format and withdraw your consent to receive notices and disclosures electronically is described below.

Consequences of changing your mind If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. To indicate to us that you are changing your mind, you must withdraw your consent using the DocuSign ‘Withdraw Consent’ form on the signing page of a

DocuSign envelope instead of signing it. This will indicate to us that you have withdrawn your consent to receive required notices and disclosures electronically from us and you will no longer be able to use the DocuSign system to receive required notices and consents electronically from us or to sign electronically documents from us.

All notices and disclosures will be sent to you electronically Unless you tell us otherwise in accordance with the procedures described herein, we will provide electronically to you through the DocuSign system all required notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you during the course of our relationship with you. To reduce the chance of you inadvertently not receiving any notice or disclosure, we prefer to provide all of the required notices and disclosures to you by the same method and to the same address that you have given

us. Thus, you can receive all the disclosures and notices electronically or in paper format through the paper mail delivery system. If you do not agree with this process, please let us know as described below. Please also see the paragraph immediately above that describes the consequences of your electing not to receive delivery of the notices and disclosures electronically from us.

Electronic Record and Signature Disclosure created on: 2/11/2018 10:43:44 PM Parties agreed to: Marilyn Bailey, Kham Noam Nang, Mitchell Bruening, Marilyn Bailey

How to contact Nebraska Department of Health & Human Services:

You may contact us to let us know of your changes as to how we may contact you electronically, to request paper copies of certain information from us, and to withdraw your prior consent to receive notices and disclosures electronically as follows:

To contact us by email send messages to: john.canfield@nebraska.gov

To advise Nebraska Department of Health & Human Services of your new e-mail address

To let us know of a change in your e-mail address where we should send notices and disclosures electronically to you, you must send an email message to us at john.canfield@nebraska.gov and in the body of such request you must state: your previous e-mail address, your new e-mail address. We do not require any other information from you to change your email address..

In addition, you must notify DocuSign, Inc. to arrange for your new email address to be reflected in your DocuSign account by following the process for changing e-mail in the DocuSign system.

To request paper copies from Nebraska Department of Health & Human Services To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must send us an e-mail to john.canfield@nebraska.gov and in the body of such request you must state your e-mail address, full name, US Postal address, and telephone number. We will bill you for any fees at that time, if any.

To withdraw your consent with Nebraska Department of Health & Human Services

To inform us that you no longer want to receive future notices and disclosures in electronic format you may:

i. decline to sign a document from within your DocuSign session, and on the subsequent page, select the check-box indicating you wish to withdraw your consent, or you may;

ii. send us an e-mail to john.canfield@nebraska.gov and in the body of such request you must state your e-mail, full name, US Postal Address, and telephone number. We do not need any other information from you to withdraw consent.. The consequences of your withdrawing consent for online documents will be that transactions may take a longer time to process..

Required hardware and software

Operating

Systems:

Windows® 2000, Windows® XP, Windows Vista®; Mac OS® X

Browsers:

Final release versions of Internet Explorer® 6.0 or above (Windows only);

Mozilla Firefox 2.0 or above (Windows and Mac); Safari™ 3.0 or above

(Mac only)

PDF Reader: Acrobat® or similar software may be required to view and print PDF files

Screen

Resolution:

800 x 600 minimum

Enabled Security

Settings:

Allow per session cookies

** These minimum requirements are subject to change. If these requirements change, you will be asked to re-accept the disclosure. Pre-release (e.g. beta) versions of operating systems and browsers are not supported.

Acknowledging your access and consent to receive materials electronically To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please verify that you were able to read this electronic disclosure and that you also were able to print on paper or electronically save this page for your future reference and access or that you were able to e-mail this disclosure and consent to an address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format on the terms and conditions described above, please let us know by clicking the ‘I agree’ button below.

By checking the ‘I agree’ box, I confirm that:

I can access and read this Electronic CONSENT TO ELECTRONIC RECEIPT OF

ELECTRONIC CONSUMER DISCLOSURES document; and

I can print on paper the disclosure or save or send the disclosure to a place where I can print it, for future reference and access; and

Until or unless I notify Nebraska Department of Health & Human Services as described above, I consent to receive from exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to me by Nebraska Department of Health & Human

Services during the course of my relationship with you.