CTR078891_TAP_Services_Sage_Counseling.pdf

TAP Provider Contract Application

Instructions Complete this form to begin the process to become a contracted provider under the Treatment Assistance Program (TAP) administered by the Arizona Department of Gaming (ADG), Division of Problem Gambling (DPG). Submitted applications are reviewed and verified by DPG staff. After verification, the application will be approved and countersigned by ADG representative to create a contract.

Note: Attachment 1 must also be completed for each individual provider under this contract application.

SECTION 1 - CONTRACTOR INFORMATION

COMPANY NAME__________________________________________________________________________________

ADDRESS________________________________________________________________________________________ City State ZIP PHONE:_______________________ FAX: _________________________ EMAIL_______________________________

Arizona Procurement Portal Supplier ID: IV______________________________________________________________

SECTION 2 - CONTRACTOR SERVICES DESCRIPTIONS

Describe your company’s target population. Include any special populations for which your company has expertise such as specific age groups, gender, geographic locations, foreign languages, ethnic groups, and presenting problems such as substance abuse, legal issues, etc.:

Describe how your company will increase the participation of affected persons in the treatment process for problem gamblers.

SECTION 3 - TYPES OF SERVICES AND REIMBURSEMENT RATES

Only the services listed in this table may be reimbursed.

TYPE DESCRIPTION REIMBURSEMENT RATE

Referrals/Sched uling Clients

The Contractor shall accept referrals for TAP services provided the client has been deemed clinically appropriate to receive services based upon an initial screening and TAP funding is available. Clients shall receive an assessment session as soon as is practical after the date of referral.

$0

Initial Screening The provider shall conduct a brief, initial screening to determine if the individual is appropriate for problem gambling treatment services.

reimbursement will not be provided for this service. Based on this screening, the Contractor will determine if a more extensive assessment is

$0

TAP Provider Contract Application v7 1

Docusign Envelope ID: C043FE4A-6D75-4BD2-AA79-CD6D51C56426

SAGE currently has over 7,000 active clients in our system of care. We believe a subset of our existing population have needs related to addiction and high-risk gambling behaviors. We plan to utilize Department-approved screening tools to identify those in need of gambling treatment services, initiate outpatient treatment groups, individual counseling, and peer support services to address the identified needs. Additionally, we plan to educate our clients bout the Self-Exclusion process, and provide assistance for those wanting to complete the self-exclusion process.

1830 S. Alma School Rd, Suite 104, Mesa, AZ 85210

(480) 649-3352

SAGE Counseling, Inc.

info@sagecounseling.net

0000017734

SAGE Counseling provides outpatient behavioral health services in Arizona. We have 14 clinics licensed by the Arizona Department of

Health Services in the following counties: Maricopa County, Pinal County, Pima County, Yuma County, Yavapai County, and Mohave

County. All of our services are available in English and Spanish, and we also provide/coordinate interpreter services for other languages. We serve clients with varying needs, and offer the following program types: 1) Addiction & Substance Abuse, 2) Domestic

Violence, 3) Anger Management, 4) Cognitive Skills, 5) Parenting, 6) Shoplifting, 7) Peer & Recovery Support. SAGE is an AHCCCS provider and contracted with all Managed Care Organizations in Arizona.

(480) 649-3358 appropriate.

Assessment The gambling treatment providers shall complete assessments on all clients deemed appropriate for the service based upon the initial screening. All assessments completed under contract with the DPG shall conform to the requirements delineated in the TAP Treatment Provider Manual.

$225 per assessment

Individual Counseling

Individual counseling shall consist of a goal-oriented process in which the client is counseled by and in the presence of a gambling treatment provider, in accordance with the treatment plan, to relieve symptoms and resolve problems related to problem or pathological gambling.

$110 per hour

Group Counseling

Group counseling shall consist of activities directly related to the attainment of objectives as defined in the written treatment plan that the gambling treatment provider provides to a minimum of two and a maximum of ten clients. Groups exceeding ten clients require preapproval from the DPG and should only occur under unusual circumstances. If such groups do not consist exclusively of problem gambling clients, the gambling treatment provider shall demonstrate that problem gambling-specific issues are adequately addressed in each group session and that the gambling treatment provider conducting the group or groups uses counseling techniques appropriate for use with problem gamblers.

$35 per hour, per client

Family Counseling

Family counseling shall consist of sessions in which the identified gambler and a minimum of one other person in a committed relationship with the identified gambler is counseled by a gambling treatment provider in accordance with the identified client’s treatment plan.

$120 per hour

Crisis Counseling (Telepractice)

The Contractor may use crisis telepractice counseling when the gambling treatment provider deems a client, who is currently active in the problem gambling treatment program, to be in crisis, and in-person counseling is not possible due to sickness or extenuating circumstances.

$110 per hour

Remote (Telepractice) Counseling

The gambling treatment provider may use telepractice counseling in cases where in-person counseling is not practical due to factors such as the client’s distance from the treatment facility, a lack of adequate transportation, or the client’s incapacity. In such cases, the gambling treatment provider shall provide the client with a DPG-approved treatment handbook to support and help structure telepractice counseling sessions.

$110 per hour

SECTION 4 - TREATMENT REQUIREMENTS

4.1. Definitions

4.1.1. CEU: Continuing Education Unit; Educational units required to maintain licensure or designation as a gambling treatment provider.

4.1.2. Clinical Consultation (Supervision) Call: Facilitated by a DPG-approved moderator, clinical consultation calls are designed to develop and enhance the skills of gambling treatment providers through discussion of pertinent clinical issues and interventions, case presentations and the liaison of agencies to improve case management of clients.

4.1.3. Continuing Education: Educational opportunities beyond formal education and initial entry level into a profession to enable practitioners to maintain competence, to become aware of new developments, and to provide responsible quality services.

4.1.4. Core Training: Sixty (60) hours of problem gambling specific training that prepares a licensed behavioral health professional to treat treatment assistance program (TAP) clients consisting of Phase I and Phase II training segments as described in the TAP Provider Manual. All training hours claimed as meeting Core Training requirements must be approved by the DPG.

TAP Provider Contract Application v7 2

Docusign Envelope ID: C043FE4A-6D75-4BD2-AA79-CD6D51C56426

4.1.5. DMS: Data Management System, further described in the TAP Provider Manual.

4.1.6. Gambling Treatment Provider: Individual providing direct counseling to clients who meet the requirements specified in this Scope of Work.

4.1.7. NCGC II: Nationally Certified Gambling Counselor II; Certification level offered by the International

Gambling Counselor Certification Board.

4.1.8. TAP: Treatment Assistance Program; the name given to the state-funded gambling treatment program.

4.1.9. TAP Provider Manual: A manual of required procedures and forms the DPG provides to each funded gambling treatment Contractor

4.2. The Treatment Assistance Provider Manual is incorporated by reference as if fully set forth herein, including any subsequent updates. The current version may be accessed through the DPG website:

https://problemgambling.az.gov/sites/default/files/Updated%20Manual%20for%20State%20Funded%20Treatment% 20for%20Problem%20Gamblers.pdf

4.3. Contractor shall comply with the requirements of the TAP Provider Manual and all subsequent updates.

4.4. If the Contractor desires to change the location at which the gambling treatment provider provides services under this Contract, the Contractor must notify and receive the approval of the DPG at least 30 days before the move takes place.

4.5. An inactive client will automatically be discharged from the DMS if no treatment activity has occurred for 90 consecutive days. The contractor should write a discharge statement for their clinical file, however the discharge within the DMS should not be completed, unless specifically requested by DPG.

4.6. The DPG requires that services which exceed 20 individual therapy sessions be authorized via an exemption request, which requires a brief clinical justification for continued treatment. Pre-discharge planning must be evident for authorization of services beyond a continuing stay review.

4.7. The Contractor shall maintain clinical records in accordance with the requirements found in the TAP Treatment Provider Manual. Contractor shall comply with all local, state and federal laws and regulations in regards to the handling and discharge of all client clinical records. The DPG or its designee shall have access to all clinical records for which TAP reimbursement has been sought for audit purposes.

4.8. Providers must:

4.8.1. Document completion of twelve (12) hours of problem gambling specific continuing education units every twelve (12) months during the contract period. If a gambling treatment provider has not completed the Core Training, continuing education hours must count toward completion of the Core Training. Participation in one DPG approved clinical consultation call may be used for 1 CEU hour up to a maximum of 6 hours to partially meet this requirement.

4.8.2. For contractors who do not bill for at least 6 months during a contract year, gambling treatment providers must document completion of 6 hours of problem gambling specific continuing education units every 12 months. Participation in one DPG approved clinical consultation call may be used for 1 CEU hour up to a maximum of 6 hours to meet this requirement.

4.9. Becoming a TAP provider is not a guarantee of work.

4.10. Contractor must complete Attachment 1 for all individual providers that will work under this contract.

SECTION 5 - INDEMNIFICATION & INSURANCE REQUIREMENTS

5.1. To the fullest extent permitted by law, Contractor shall defend, indemnify, and hold harmless the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees (hereinafter referred to as “Indemnitee”) from and against any and all claims, actions, liabilities, damages, losses, or expenses (including court costs, attorneys’ fees, and costs of claim processing, investigation and litigation) (hereinafter referred to as “Claims”) for bodily injury or personal injury (including death), or loss or damage to tangible or intangible property caused, or alleged to be caused, in whole or in part, by the negligent or willful acts or omissions of Contractor or any of its owners, officers, directors, agents, employees or Subcontractors. This indemnity includes any claim or amount arising out of, or recovered under, the Workers’ Compensation Law or arising out of the failure of such Contractor to conform to any federal, state, or local law, statute, ordinance, rule, regulation, or court decree. It is the specific intention of the parties that the Indemnitee shall, in all instances, except for Claims arising solely from the negligent or willful acts or omissions of the Indemnitee, be indemnified by Contractor from and against any and all claims. It is agreed that the Contractor will be responsible for primary loss investigation, defense, and judgment costs where this indemnification is applicable. In consideration of the award of this contract, the Contractor agrees to waive all rights of subrogation against the State of Arizona, its officers, officials, agents, and employees for losses arising from the work performed by the Contractor for the State of Arizona. This indemnity shall not apply if the Contractor or Subcontractor(s) is/are an agency, board, commission or university of the State of Arizona.

TAP Provider Contract Application v7 3

Docusign Envelope ID: C043FE4A-6D75-4BD2-AA79-CD6D51C56426 https://problemgambling.az.gov/sites/default/files/Updated%20Manual%20for%20State%20Funded%20Treatment%20for%20Problem%20Gamblers.pdf https://problemgambling.az.gov/sites/default/files/Updated%20Manual%20for%20State%20Funded%20Treatment%20for%20Problem%20Gamblers.pdf

5.2. Contractor and subcontractors shall procure and maintain, until all of their obligations have been discharged, including any warranty periods under this Contract, insurance against claims for injury to persons or damage to property arising from, or in connection with, the performance of the work hereunder by the Contractor, its agents, representatives, employees or subcontractors.

5.3. The Insurance Requirements herein are minimum requirements for this Contract and in no way limit the indemnity covenants contained in this Contract. The State of Arizona in no way warrants that the minimum limits contained herein are sufficient to protect the Contractor from liabilities that arise out of the performance of the work under this Contract by the Contractor, its agents, representatives, employees or subcontractors, and the Contractor is free to purchase additional insurance.

5.4. Contractor shall provide coverage with limits of liability not less than those stated below.

5.4.1. Commercial General Liability (CGL) – Occurrence Form. Policy shall include bodily injury, property damage, contractual liability coverage.

● General Aggregate - $2,000,000

● Products – Completed Operations Aggregate - $1,000,000

● Personal and Advertising Injury -$1,000,000

● Damage to Rented Premises - $50,000

● Each Occurrence - $1,000,000

● The policy shall be endorsed, as required by this written agreement, to include the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees as additional insureds with respect to liability arising out of the activities performed by or on behalf of the Contractor.

● Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

5.4.2. Workers’ Compensation and Employers' Liability

● Workers' Compensation - Statutory

● Employers' Liability

○ Each Accident - $1,000,000

○ Disease – Each Employee - $1,000,000

○ Disease – Policy Limit - $1,000,000

● Policy shall contain a waiver of subrogation endorsement, as required by this written agreement, in favor of the State of Arizona, and its departments, agencies, boards, commissions, universities, officers, officials, agents, and employees for losses arising from work performed by or on behalf of the Contractor.

● This requirement shall not apply to each Contractor or subcontractor that is exempt under A.R.S. § 23-901, and when such Contractor or subcontractor executes the appropriate waiver form (Sole Proprietor or Independent Contractor).

5.4.3. Professional Liability (Errors and Omissions Liability)

● Each Claim - $2,000,000

● Annual Aggregate - $2,000,000

● In the event that the Professional Liability insurance required by this Contract is written on a claims-made basis, Contractor warrants that any retroactive date under the policy shall precede the effective date of this Contract and, either continuous coverage will be maintained, or an extended discovery period will be exercised, for a period of two (2) years beginning at the time work under this Contract is completed.

● The policy shall cover professional misconduct or negligent acts for those positions defined in the Scope of Work of this contract.

5.5. Additional Insurance Requirements. The policies shall include, or be endorsed to include, as required by this written agreement, the following provisions:

5.5.1. The Contractor's policies, as applicable, shall stipulate that the insurance afforded the Contractor shall be primary and that any insurance carried by the Department, its agents, officials, employees or the State of Arizona shall be excess and not contributory insurance, as provided by A.R.S. § 41-621 (E).

5.5.2. Insurance provided by the Contractor shall not limit the Contractor’s liability assumed under the indemnification provisions of this Contract.

5.6. Notice of Cancellation. Applicable to all insurance policies required within the Insurance Requirements of this Contract, Contractor’s insurance shall not be permitted to expire, be suspended, be canceled, or be materially changed for any reason without thirty (30) days prior written notice to the State of Arizona. Within two (2) business days of receipt, Contractor must provide notice to the State of Arizona if they receive notice of a policy that has

TAP Provider Contract Application v7 4 been or will be suspended, canceled, materially changed for any reason, has expired, or will be expiring. Such notice shall be sent directly to the Department and shall be mailed, emailed, hand delivered or sent by facsimile transmission to Arizona Department of Gaming, 100 N 15th Ave., Ste. 202, Phoenix, AZ 85007.

5.7. Acceptability of Insurers. Contractor’s insurance shall be placed with companies licensed in the State of Arizona or hold approved non-admitted status on the Arizona Department of Insurance List of Qualified Unauthorized Insurers.

Insurers shall have an “A.M. Best” rating of not less than A- VII. The State of Arizona in no way warrants that the above-required minimum insurer rating is sufficient to protect the Contractor from potential insurer insolvency.

5.8. Verification of Coverage. Contractor shall furnish the State of Arizona with certificates of insurance (valid ACORD form or equivalent approved by the State of Arizona) evidencing that Contractor has the insurance as required by this Contract. An authorized representative of the insurer shall sign the certificates.

5.8.1. All such certificates of insurance and policy endorsements must be received by the State before work commences. The State’s receipt of any certificates of insurance or policy endorsements that do not comply with this written agreement shall not waive or otherwise affect the requirements of this agreement.

5.8.2. Each insurance policy required by this Contract must be in effect at, or prior to, commencement of work under this Contract. Failure to maintain the insurance policies as required by this Contract, or to provide evidence of renewal, is a material breach of contract.

5.8.3. All certificates required by this Contract shall be sent directly to the Department. The State of Arizona project/contract number and project description shall be noted on the certificate of insurance. The State of Arizona reserves the right to require complete copies of all insurance policies required by this Contract at any time.

5.9. Subcontractors. Contractor’s certificate(s) shall include all subcontractors as insureds under its policies or Contractor shall be responsible for ensuring and/or verifying that all subcontractors have valid and collectable insurance as evidenced by the certificates of insurance and endorsements for each subcontractor. All coverages for subcontractors shall be subject to the minimum Insurance Requirements identified above. The Department reserves the right to require, at any time throughout the life of this contract, proof from the Contractor that its subcontractors have the required coverage.

5.10. Approval and Modifications. The Contracting Agency, in consultation with State Risk, reserves the right to review or make modifications to the insurance limits, required coverages, or endorsements throughout the life of this contract, as deemed necessary. Such action will not require a formal Contract amendment but may be made by administrative action.

5.11. Exceptions. In the event the Contractor or subcontractor(s) is/are a public entity, then the Insurance Requirements shall not apply. Such public entity shall provide a certificate of self-insurance. If the Contractor or subcontractor(s) is/are a State of Arizona agency, board, commission, or university, none of the above shall apply.

Attach Certificate of Insurance that complies with the requirements above:

SECTION 6 - ADDITIONAL TERMS AND CONDITIONS

6.1. Term of Contract. The term of the Contract will commence on the Effective Date and continue for twelve (12) months unless canceled, terminated, or permissibly extended.

6.2. Contract Extensions. State may at its discretion extend the initial Contract term in increments of one (1) or more months and do so one or more times, provided that the maximum aggregate term of the Contract including extensions cannot exceed the maximum aggregate term of five (5) years.

6.3. State Law Certifications. If Contractor is a Company as defined in A.R.S. § 35-393 and 35-394, Contractor certifies that it shall comply with A.R.S. § 35-394, regarding use of forced labor of ethnic Uyghurs, as applicable. If reimbursements under this Contract exceed $100,000, Contractor further certifies that it is not currently engaged in a boycott of Israel as described in A.R.S. §§ 35-393 et seq. and will refrain from any such boycott for the duration of this Contractor.

6.4. Data and Information Handling.

6.4.1. Section 6.4 applies to the extent the Work includes handling of any (1) State’s proprietary and sensitive data or (2) confidential or access-restricted information obtained from State or from others at State’s behest.

6.4.2. Data Protection and Confidentiality of Information. Contractor warrants that it will establish and maintain procedures and controls acceptable to State for ensuring that State’s proprietary and sensitive data is protected from unauthorized access and information obtained from State or others in performance of its contractual duties is not mishandled, misused, or inappropriately released or disclosed. For purposes of

TAP Provider Contract Application v7 5 this paragraph, all data created by Contractor in any way related to the Contract, provided to Contractor by State, or prepared by others for State are proprietary to State, and all information by those same avenues is State’s confidential information. To comply with the foregoing warrant:

6.4.2.1. Contractor shall: (a) notify State immediately of any unauthorized access or inappropriate disclosures, whether stemming from an external security breach, internal breach, system failure, or procedural lapse; (b) cooperate with State to identify the source or cause and respond to each unauthorized access or inappropriate disclosure; and (c) notify State promptly of any security threat that could result in unauthorized access or inappropriate disclosures; and

6.4.2.2. Contractor shall not: (a) release any such data or allow it to be released or divulge any such information to anyone other than its employees or officers as needed for each person’s individual performance of his or her duties under the Contract, unless State has agreed otherwise in advance and in writing; or (b) respond to any requests it receives from a third party for such data or information, and instead route all such requests to State’s designated representative.

6.4.3. Personally Identifiable Information. Without limiting the generality of paragraph 14.2, Contractor warrants that it will protect any personally identifiable information (“PII”) belonging to State’s employees or other contractors or members of the general public that it receives from State or otherwise acquires in its performance under the Contract. For purposes of this paragraph:

6.4.3.1. PII has the meaning given in the [federal] Office of Management and Budget (OMB)

Memorandum M-17-12 Preparing for and Responding to a Breach of Personally Identifiable Information, January 3, 2017; and

6.4.3.2. “protect” means taking measures to safeguard personally identifiable information and prevent its breach that are functionally equivalent to those called for in that OMB memorandum and elaborated on in the [federal] General Services Administration (GSA) Directive CIO P 2180.1 GSA Rules of Behavior for Handling Personally Identifiable Information.

NOTE (1): For convenience of reference only, the OMB memorandum is available at:

https://dpcld.defense.gov/Privacy/Authorities-and-Guidance/ NOTE (2): For convenience of reference only, the GSA directive is available at:

https://www.gsa.gov/directive/gsa-rules-of-behavior-for-handling-personally-identifiable-in formation-(pii)-

6.4.4. Protected Health Information. Contractor warrants that, to the extent performance under Contract involves individually identifiable health information (referred to hereinafter as protected health information (“PHI”) and electronic PHI (“ePHI”) as defined in the Privacy Rule referred to below), it:

6.4.4.1. is familiar with and will comply with the applicable aspects of the following collective regulatory requirements regarding patient information privacy protection: (a) the “Privacy Rule” in CFR 45 Part 160 and Part 164 pursuant to the Health Insurance Portability and Accountability Act (“HIPAA”) of 1996; (b) Arizona laws, rules, and regulations applicable to PHI/ePHI that are not preempted by CFR45-160(B) or the Employee Retirement Income Security Act of 1974 (“ERISA”) as amended; and (c) State’s current and published PHI/ePHI privacy and security policies and procedures;

6.4.4.2. will cooperate with State in the course of performing under the Contract so that both State and Contractor stay in compliance with the requirements in (1) above; and

6.4.4.3. will sign any documents that are reasonably necessary to keep both State and Contractor in compliance with the requirements in (1) above, in particular “Business Associate Agreements” in accordance with the Privacy Rule.

NOTE: For convenience of reference only, the Privacy Rule is available at:

http://www.hhs.gov/hipaa/for-professionals/privacy/index.html

6.5. The State of Arizona Uniform Terms and Conditions are incorporated into this Contract by reference as if fully set forth herein.

6.5.1. This contract application serves as the “solicitation” as defined in the Uniform Terms and Conditions.

6.5.2. Section 4.1 of the Uniform Terms and Conditions is replaced with: 4.1 Payments. Payments shall comply with the requirements of A.R.S. Titles 35 and 41, Net 10 days. Upon receipt and acceptance of Materials or Services, the Contractor shall submit a complete and accurate invoice for payment from the State within thirty (30) days.

6.5.3. The current version may be accessed at:

https://spointra.az.gov/sites/default/files/Uniform%20Terms%20and%20Conditions_r10.5_03-24.pdf

TAP Provider Contract Application v7 6

Docusign Envelope ID: C043FE4A-6D75-4BD2-AA79-CD6D51C56426 https://dpcld.defense.gov/Privacy/Authorities-and-Guidance/ https://www.gsa.gov/directive/gsa-rules-of-behavior-for-handling-personally-identifiable-information-(pii)-https://www.gsa.gov/directive/gsa-rules-of-behavior-for-handling-personally-identifiable-information-(pii)-http://www.hhs.gov/hipaa/for-professionals/privacy/index.html https://spo.az.gov/sites/default/files/2025-05/Uniform%20Terms%20and%20Conditions_r10.5_03-24.pdf

SECTION 7 - Signatures

I certify that the information provided on this contract application is true and correct. By signing below, each signatory certifies their authority to bind their respective party to this Contract.

For and on behalf of the Contractor:

Signature of Authorized Individual

Printed Name

Title

Date

For and on behalf of the Arizona Department of Gaming:

Signature of Authorized Individual

Printed Name

Title

Date

Contract Number:______________________________

Contract Effective Date:_________________________

DPG Application Verification

Verification Completed by:_______________________

Verification Date:______________________________

TAP Provider Contract Application v7 7

Michael Peugnet

Chief Operations Officer

9/17/2025

9/17/2025

9/30/25

Abby Medina Silas

CTR078891

Chief Procurement Officer

9/29/2025