CTR056041 Grant Amend Summ 1.pdf

GRANT

AMENDMENT

ARIZONA DEPARTMENT OF

HEALTH SERVICES

OFFICE OF PROCUREMENT

150 N 18th Ave., Ste. #530 Phoenix, Arizona 85007

GRANT NO.: CTR056041 AMENDMENT NO.: 1 Procurement Officer Delilah Gonzalez

Investigator Grant - Adler

Effective upon signature by both parties, it is mutually agreed that the Grant referenced in this amendment is amended as follows:

1. Pursuant to the Terms and Conditions, Provision Five (4), Grant Changes, section 4.1 Amendments, the Grant is hereby revised with the following:

1.1. Provision 2, Section 2.1, Grant Period, is revised and replaced with the following:

The Grant shall be effective July 1, 2021 or upon final signature, whichever is later (“Effective Date”) and shall remain in effect for three (3) years unless terminated, canceled, or extended as otherwise provided herein.

1.2. In reference to Provision Two (2) Grant Period, the Grant is hereby extended through July 1, 2023.

ALL OTHER PROVISIONS SHALL REMAIN IN THEIR ENTIRETY

Contractor hereby acknowledges receipt and acceptance of above amendment and that a signed copy must be filed with the Procurement Office before the effective date

The above referenced Contract Amendment is hereby executed this _____ day of __________ 20______ at Phoenix, Arizona

(To be filled out by ADHS Procurement Office)

Contractor Signature

Contractor Signature Date

Authorized Signatory’s Name and Title

MAYO CLINIC ARIZONA

Contractor’s Name Procurement Officer Signature

Certificate Of Completion Envelope Id: CCDA9552887F4285B794416494410114 Status: Completed Subject: Arizona Department of Health Services/Charles H. Adler, M.D., Ph.D./ARI-290450-01/FP00104196-A1-PR02 Source Envelope:

Document Pages: 1 Signatures: 2 Envelope Originator:

Certificate Pages: 2 Initials: 0 Rhonda Larson AutoNav: Enabled EnvelopeId Stamping: Enabled Time Zone: (UTC-06:00) Central Time (US & Canada)

200 1st St SW Rochester, MN 55905 Larson.Rhonda@mayo.edu IP Address: 65.36.178.209

Record Tracking Status: Original

7/6/2022 8:25:08 AM

Holder: Rhonda Larson Larson.Rhonda@mayo.edu

Location: DocuSign

Signer Events Signature Timestamp Tara Rabe rabe.tara@mayo.edu Administrator Mayo Clinic Security Level: Email, Account Authentication (Optional)

Signature Adoption: Pre-selected Style Using IP Address: 129.176.151.15

Sent: 7/6/2022 8:27:51 AM Viewed: 7/6/2022 8:29:01 AM Signed: 7/6/2022 8:29:06 AM

Electronic Record and Signature Disclosure:

Not Offered via DocuSign

Delilah Gonzalez delilah.gonzalez@azdhs.gov Security Level: Email, Account Authentication (Optional)

Signature Adoption: Pre-selected Style Using IP Address: 159.36.3.213

Sent: 7/6/2022 8:29:08 AM Viewed: 7/8/2022 10:26:12 AM Signed: 7/8/2022 2:30:43 PM

Electronic Record and Signature Disclosure:

Not Offered via DocuSign

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 Charles H. Adler, M.D., Ph.D.

cadler@mayo.edu Security Level: Email, Account Authentication (Optional)

Sent: 7/8/2022 2:30:45 PM

Electronic Record and Signature Disclosure:

Not Offered via DocuSign

Carbon Copy Events Status Timestamp Laurie L. Winslow Winslow.Laurie@mayo.edu Security Level: Email, Account Authentication (Optional)

Sent: 7/8/2022 2:30:46 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 7/6/2022 8:27:51 AM Certified Delivered Security Checked 7/8/2022 10:26:12 AM Signing Complete Security Checked 7/8/2022 2:30:43 PM Completed Security Checked 7/8/2022 2:30:46 PM

Payment Events Status Timestamps

Entity Details

Statutory Agent Information

Principal Information

Entity Name: MAYO CLINIC ARIZONA Entity ID: 07513455

Entity Type:

Domestic Nonprofit Corporation

Entity Status: Active

Formation Date: 6/14/1995 Reason for Status:

Approval Date: 6/14/1995 Status Date:

Original Incorporation Date: 6/14/1995 Life Period: Perpetual

Business Type: HOSPITAL/HEALTH CARE Last Annual Report Filed: 2022

Domicile State: Arizona Annual Report Due Date: 5/14/2023

Years Due:

Origninal Publish Date: 7/14/1995

Name: Peter Galindez Appointed Status: Active 2/15/2022

Attention:

Address:

13400 East Shea Blvd, SCOTTSDALE, AZ 85259, USA

Agent Last Updated: 4/5/2022

Attention: Mailing Address:

E-mail: galindez.peter@mayo.edu County:

Title Name Address Date of Taking Office

Last Updated

Director

ALYSSA B

CHAPITAL MD

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

1/1/2017 4/8/2019

Director AMY K HARA MD

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

1/1/2017 4/8/2019

Director

BREEANN M

ADLEMAN

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

4/7/2016 4/8/2019

Director

JOHN N

CAVINESS

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

1/1/2016 4/8/2019

In Good Standing

Arizona Corporation Commission Corporations Division Website Entity Detail. http://ecorp.azcc.gov/

Arizona Corporation Commission Page 1 of 3Page 1 of 3Page 1 of 3

8/9/2022 2:31:36 PM8/9/2022 2:31:36 PM8/9/2022 2:31:36 PM

Director

DIANE F JELINEK

PHD

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

8/3/2015 4/8/2019

Director SEAN W GLENN

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

5/20/2015 4/8/2019

Director

PAULA E

MENKOSKY

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

11/15/2012 4/8/2019

Director

RAFAEL

FONSECA MD

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

2/1/2012 4/8/2019

Director

PAUL E

ANDREWS MD

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

1/18/2012 4/8/2019

Officer

PAUL E

ANDREWS MD

13400 E. SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

1/1/2018 4/8/2019

Officer PETER GALINDEZ

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

7/12/2017 4/8/2019

Officer SEAN W GLENN

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

5/20/2015 4/8/2019

Officer

BREEANN M

ADLEMAN

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

1/1/2015 4/8/2019

Secretary

PAULA E

MENKOSKY

13400 E SHEA BLVD, SCOTTSDALE, AZ,

85259, Maricopa County, USA

11/15/2012 4/8/2019

CEO (Chief Executive Officer)

Richard J Gray 13400 East Shea Blvd, SCOTTSDALE, AZ, 85259, Maricopa County, USA

5/10/2019 4/28/2020

Chairman of the Board of Directors

Richard J Gray 13400 East Shea Blvd, SCOTTSDALE, AZ, 85259, Maricopa County, USA

5/10/2019 4/28/2020

Officer Katherine H Noe 13400 East Shea Blvd, SCOTTSDALE, AZ, 85259, Maricopa County, USA

1/1/2020 4/28/2020

Treasurer Allison L Viramontes

13400 EAST SHEA BOULEVARD,

SCOTTSDALE, AZ, 85259, Maricopa County, USA

5/13/2020 4/20/2021

Officer Allison L Viramontes

13400 EAST SHEA BOULEVARD,

SCOTTSDALE, AZ, 85259, Maricopa County, USA

5/13/2020 4/20/2021

Officer Brian W Chong

13400 EAST SHEA BOULEVARD,

SCOTTSDALE, AZ, 85259, Maricopa County, USA

1/1/2020 4/20/2021

Officer Lisa M Rimsza

13400 EAST SHEA BOULEVARD,

SCOTTSDALE, AZ, 85259, Maricopa County, USA

1/1/2021 4/20/2021

Arizona Corporation Commission Corporations Division Website Entity Detail. http://ecorp.azcc.gov/

Arizona Corporation Commission Page 2 of 3Page 2 of 3Page 2 of 3

8/9/2022 2:31:37 PM8/9/2022 2:31:37 PM8/9/2022 2:31:37 PM

Entity Known Place of Business

Entity Principal Office Address

Officer Devyani Lal 13400 East Shea Boulevard, SCOTTSDALE, AZ, 85259, Maricopa County, USA

6/2/2021 4/5/2022

Officer Marialena Murphy 13400 East Shea Boulevard, SCOTTSDALE, AZ, 85259, Maricopa County, USA

1/1/2021 4/5/2022

Officer Alyx B Porter 13400 East Shea Boulevard, SCOTTSDALE, AZ, 85259, Maricopa County, USA

1/1/2021 4/5/2022

Address:

13400 East Shea Boulevard, SCOTTSDALE, AZ, 85259, USA

County: Maricopa Last Updated: 4/5/2022

Address: County: Last Updated:

Arizona Corporation Commission Corporations Division Website Entity Detail. http://ecorp.azcc.gov/

Arizona Corporation Commission Page 3 of 3Page 3 of 3Page 3 of 3

8/9/2022 2:31:38 PM8/9/2022 2:31:38 PM8/9/2022 2:31:38 PM

MAYO CLINIC ARIZONA

Unique Entity ID

ULMJJBL7ZXX3

CAGE / NCAGE

1TZ60

Purpose of Registration

All Awards

Registration Status

Active Registration

Expiration Date

Oct 15, 2022

Physical Address

13400 E Shea BLVD

Scottsdale, Arizona 85259-5404

United States

Mailing Address

Johnson Research Building 1ST Floor Ospa

13400 E. Shea BLVD

Scottsdale, Arizona 85259-5404

United States

Business Information

Doing Business as

MAYO CLINIC HOSPITAL

Division Name

(blank)

Division Number

(blank)

Congressional District

Arizona 06

State / Country of Incorporation

Arizona / United States

URL

HTTP://WWW.MAYO.EDU/MCS/

Registration Dates

Activation Date

Sep 21, 2021

Submission Date

Sep 15, 2021

Initial Registration Date

May 21, 2001

Entity Dates

Entity Start Date

Jan 1, 1997

Fiscal Year End Close Date

Dec 31

Immediate Owner

CAGE

5A021

Legal Business Name

MAYO CLINIC

Highest Level Owner

CAGE

(blank)

Legal Business Name

(blank)

Executive Compensation

Registrants in the System for Award Management (SAM) respond to the Executive Compensation questions in accordance with Section 6202 of

P.L. 110-252, amending the Federal Funding Accountability and Transparency Act (P.L. 109-282). This information is not displayed in SAM. It is sent to USAspending.gov for display in association with an eligible award. Maintaining an active registration in SAM demonstrates the registrant responded to the questions.

Proceedings Questions

Registrants in the System for Award Management (SAM) respond to proceedings questions in accordance with FAR 52.209-7, FAR 52.209-9, or

2.C.F.R. 200 Appendix XII. Their responses are not displayed in SAM. They are sent to FAPIIS.gov for display as applicable. Maintaining an active registration in SAM demonstrates the registrant responded to the proceedings questions.

Exclusion Summary

Active Exclusions Records?

No

SAM Search Authorization

I authorize my entity's non-sensitive information to be displayed in SAM public search results:

Yes

Entity Types

Business Types

Entity Structure

Corporate Entity (Tax Exempt)

Entity Type

Business or Organization

Organization Factors

(blank)

Profit Structure

Non-Profit Organization

Last updated by Paul Haines on Sep 15, 2021 at 02:42 PM MAYO CLINIC ARIZONA https://sam.gov/entity/ULMJJBL7ZXX3/coreData?status=Active Page 1 of 2

Socio-Economic Types

Check the registrant's Reps & Certs, if present, under FAR 52.212-3 or FAR 52.219-1 to determine if the entity is an SBA-certified HUBZone small business concern. Additional small business information may be found in the SBA's Dynamic Small Business Search if the entity completed the

SBA supplemental pages during registration.

Other Entity Qualifiers

Hospital

Financial Information

Accepts Credit Card Payments

No

Debt Subject To Offset

No

EFT Indicator

CAGE Code

1TZ60

Points of Contact

Electronic Business

Craig Stewart, Institutional Official 13400 E. Shea BLVD.

Scottsdale, Arizona 85259

United States

Gregory thomas 13400 E. Shea BLVD.

Scottsdale, Arizona 85259

United States

Government Business

Paul Haines 13400 E. Shea BLVD

Scottsdale, Arizona 85259

United States

Gregory Thomas Mayo Clinic Arizona

13400 E. Shea BLVD

Scottsdale, Arizona 85259

United States

Past Performance

Craig Stewart 13400 East Shea BLVD

Scottsdale, Arizona 85259

United States

Jon A Lindeen 13400 East Shea BLVD

Scottsdale, Arizona 85259

United States

Service Classifications

NAICS Codes

Primary

Yes

NAICS Codes

541715

NAICS Title

Research And Development In The Physical, Engineering, And Life

Sciences (Except Nanotechnology And Biotechnology)

541714 Research And Development In Biotechnology (Except

Nanobiotechnology)

621111 Offices Of Physicians (Except Mental Health Specialists)

Product and Service Codes

PSC PSC Name

AF11 R&D- Education: Educational (Basic Research)

AN41 R&D- Medical: Health Services (Basic Research)

Disaster Response

This entity does not appear in the disaster response registry.

Last updated by Paul Haines on Sep 15, 2021 at 02:42 PM MAYO CLINIC ARIZONA https://sam.gov/entity/ULMJJBL7ZXX3/coreData?status=Active Page 2 of 2

8/9/22, 2:33 PM OIG Search Results https://exclusions.oig.hhs.gov/SearchResults.aspx 1/1

Visit our tips page to learn how to best use the Exclusions Database. If you experience technical difficulties, please email the webmaster at webmaster@oig.hhs.gov.

Exclusions Search Results:

Exclusions Search Results:

EntitiesEntities

No Results were found for

Mayo Clinic Arizona

If no results are found, this individual or entity (if it is an entity search) is not currently excluded. Print this Web page for your documentation

Search Again

Search conducted 8/9/2022 5:32:12 PM EST on OIG LEIE Exclusions database.

Source data updated on 7/29/2022 8:00:00 PM EST

Return to Search

An official website of the United States government. Here's how you know > https://oig.hhs.gov/exclusions/exclusions-help.asp#generalSearch mailto:webmaster@oig.hhs.gov https://oig.hhs.gov/exclusions/exclusions-help.asp#entitySearch javascript:__doPostBack('ctl00$cpExclusions$lbGridBackToSearch','') javascript:__doPostBack('ctl00$cpExclusions$lbBackToSearch','') https://oig.hhs.gov/notices/official-site.asp