ISA_ASU-ACDHH_HHCP.pdf

INTERAGENCY SERVICE AGREEMENT

Begin Date: May 17, 2021 ACDHH Contract No:

Termination Date: June 30, 2022

This Interagency Service Agreement (“Agreement”) is between the ARIZONA BOARD OF

REGENTS FOR AND ON BEHALF OF ARIZONA STATE UNIVERSITY COLLEGE OF HEALTH

SOLUTIONS (“ASU CHS”) and its SPEECH AND HEARING CLINIC (“SHC”) and the ARIZONA COMMISSION FOR THE DEAF AND THE HARD OF HEARING (“ACDHH”). ASU CHS - SHC and ACDHH are sometimes individually or collectively referred to as a “Party” or the “Parties”.

BACKGROUND & PURPOSE

A. ACDHH recognizes that a lack of resources leaves many low-income adult Arizonans without access to hearing healthcare services. As such, ACDHH wishes to help alleviate this lack of access to hearing healthcare by funding hearing healthcare services at ASU CHS - SHC.

B. ASU CHS - SHC proposes to provide hearing healthcare devices and services to low-income adult Arizonans (“Client”) who lack access to these devices and services.

C. ACDHH is authorized to enter into this Agreement pursuant to A.R.S. § 36-1943(A) (Providing “[w]ith the approval of the commission, the executive director may contract for professional, technical and clerical services necessary to carry out functions of the commission”). Pursuant to A.R.S. §§ 36-1944, 1943, ACDHH mission and duties encompass the study of issues related to the deaf and the hard of hearing; the review, administration and operation of programs; the review of the need for effective communication involving the deaf and hard of hearing community; the study of appropriate auxiliary aids and acoustical devices, and advocacy for the provision of these services.

NOW THEREFORE, in consideration of the mutual covenants and promises contained herein, ASU- SHC and ACDHH agree as follows:

I. PROJECT DIRECTOR AND PERIOD OF PERFORMANCE

The Project will be under the supervision and direction of Kristin Samuelson, Au.D., CCC-A, and Joshua Breger, M.S., CCC-SLP, employees of ASU.

II. TERM OF AGREEMENT

The period of performance shall start on May 17, 2021 and end on June 30, 2022. This agreement can be renewed annually each Fiscal year upon written mutual agreement of each party.

III. SCOPE OF WORK

Exhibit A, Scope of Work, is incorporated herein by reference, as fully if set forth herein.

CTR055269

IV. PROPERTY ADMINISTRATION

Upon termination of this Agreement, any equipment, material, or supplies remaining in stock will become the property of ASU.

V. BILLING AND PAYMENT

The payment schedule is in Exhibit B.

A. Under this Agreement, the Budget (Exhibit B) is incorporated herein as fully as if set forth herein. The total amount, agreed upon by the Parties, shall not exceed $100,000.00 per fiscal year.

B. Payments shall comply with the requirements of A.R.S. Titles 35 and 41, net 30 days. ASU shall submit to ACDHH complete and accurate expenditure reports/invoices within thirty

(30) days of receipt, as provided in the Arizona Accounting Manual.

C. Invoices will be sent to the following address of ACDHH:

Attn: Carlos Castillo, Business Manager

Arizona Commission for the Deaf and the Hard of Hearing 100 N. 15th Avenue, Suite 104

Phoenix, AZ 85007 C.Castillo@acdhh.az.gov

With a copy to:

Michele Michaels Hearing Healthcare Program Manager, ACDHH 100 N. 15th Ave., Suite 104 Phoenix, AZ 85007 M.Michaels@acdhh.az.gov

VI. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996

ASU CHS - SHC certifies that it is familiar with the requirements of HIPAA, as amended by the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009, and accompanying regulations and will comply with all applicable HIPAA requirements in the course of this Agreement. ASU CHS - SHC certifies that it will cooperate with ACDHH in the course of performance of the Agreement so that both ACDHH and ASU will be in compliance with HIPAA, including cooperation and coordination with the Arizona Department of Administration- Arizona Strategic Enterprise Technology (ADOA-ASET) Office, the ADOA-ASET Arizona State Chief Information Security Officer and HIPAA Coordinator, and other compliance officials required by HIPAA and its regulations. ASU will sign any documents that are reasonably necessary to keep ACDHH and ASU in compliance with HIPAA.

ASU shall abide by HIPAA requirements addressing the creation, use and disclosure of confidential information, including information designated as protected health information mailto:M.Michaels@acdhh.az.gov and all other confidential or sensitive information as defined in policy. In addition, if requested, ASU agrees to provide upon request written verification that all relevant ASU CHS

- SHC employees have attended or participated in job related HIPAA training that is: (1) intended to make ASU CHS - SHC proficient in HIPAA for purposes of performing the services required and (2) presented by a HIPAA Privacy Officer or other person or program knowledgeable and experienced in HIPAA and who has been approved by the ADOA-ASET Arizona State Chief Information Security Officer and HIPAA Coordinator.

VII. BACKGROUND CHECKS

If providing direct services to vulnerable adults, the following shall apply:

a. ASU shall comply with, and shall ensure that all of ASU’s employees, independent contractors, subcontractors, volunteers and other agents comply with, all applicable (current and future) legal requirements relating to fingerprinting, fingerprint clearance cards, certifications regarding pending or past criminal matters, and criminal records checks that relate to contract performance.

b. Applicable legal requirements relating to fingerprinting, certification, and criminal background checks may include, but are not limited, to the following: A.R.S. §§ 36-594.01, 36-3008, 41-1964, and 46-141. All applicable legal requirements relating to fingerprinting, fingerprint clearance cards, certifications regarding pending or past criminal matters, and criminal records checks are hereby incorporated in their entirety as provisions of this contract. ASU is responsible for knowing which legal requirements relating to fingerprinting, fingerprint clearance cards, certifications regarding pending or past criminal matters, and criminal records checks relate to contract performance.

c. To the extent A.R.S. § 46-141 is applicable to ASU’s performance or the services provided under this Agreement, the following provisions apply:

i. Personnel who are employed by ASU, whether paid or not, and who are required or allowed to provide services directly to vulnerable adults shall have a valid fingerprint clearance card or shall apply for a fingerprint clearance card within seven working days of employment.

ii. Except as provided in A.R.S. § 46-141, this Agreement may be cancelled or terminated immediately if a person employed by ASU and who has contact with vulnerable adults certifies pursuant to the provisions of A.R.S. § 46-141 (as may be amended) is awaiting trial or has been convicted of any of the offenses listed therein in this State, or of acts committed in another state that would be offenses in this State, or if the person does not possess or is denied issuance of a valid fingerprint clearance card.

VIII. INSURANCE AND LIABILITY

The UNIVERSITY maintains general liability insurance and workman's compensation coverage as required by state law and pertinent federal laws and regulations. In the event ACDHH undertakes to perform any work on the premises of ASU, then ACDHH shall give assurances to

ASU of ACDHH's adequate general liability insurance and workman's compensation coverage.

It is understood, however, that neither Party to this Agreement is the agent of the other and neither is liable for the wrongful acts or negligence of the other. Each party shall be solely responsible and liable for all claims, demands or judgments (including costs, expenses, and attorney’s fees) arising out of bodily injury to any person or damage to any property caused by the acts or omissions of its employees, agents, or subcontractors.

IX. REPORTS

Within thirty (30) days upon completion of any services listed in the Scope of Work, ASU will submit to the Hearing Healthcare Program at ACDHH a detailed technical report of the services provided to each Client or Recipient, as required. It is understood, however, that ASU shall not be restricted from publishing the results of the Project. If the results of the Project are published, ASU agrees to acknowledge the support received from the ACDHH.

X. CONFIDENTIAL INFORMATION

ACDHH and ASU may choose, from time to time, in connection with work contemplated under this Agreement, to disclose confidential information to each other (Confidential Information).

All such disclosures must be in writing and marked as Confidential Information. The Parties will use reasonable efforts to prevent the disclosure to unauthorized third parties of any Confidential Information of the other Party and will use such information only for the purposes of this Agreement, and for three (3) years after the termination of this Agreement; provided that the receiving Party’s obligations hereunder shall not apply to information that:

a. is already in the receiving Party’s possession at the time of disclosure; or,

b. is or later becomes part of the public domain through no fault of the receiving

Party’s; or,

c. is received from a third party with no duty of confidentiality to the disclosing

Party; or,

d. was developed independently by the receiving Party prior to disclosure; or,

e. is required to be disclosed by law or regulation.

Any information that is transmitted orally or visually, in order to be protected hereunder, shall be identified as such by the disclosing Party at the time of disclosure, and identified in writing to the receiving Party, as Confidential Information, within thirty (30) days after such oral or visual disclosure.

XI. INTELLECTUAL PROPERTY RIGHTS

Neither Party will make, conceive, discover, develop or create, either solely or jointly with any other person or persons, any trade secrets, inventions, developments, or discoveries, works of authorship, whether patentable or not (collectively referred to as "Intellectual Property") under this Agreement or the Scope of Work. Nothing in this Agreement shall be construed as an assignment of any Intellectual Property.

XII. TERMINATION

ASU may terminate this Agreement at any time upon thirty (30) days written notice to ACDHH, if: (a) cost-reimbursement, funding for the Project is fully expended; or (b) circumstances beyond its control preclude continuation of the Project. ACDHH may terminate this Agreement at any time upon thirty (30) days written notice to ASU, if circumstances beyond its control preclude continuation of the Project. In the event that either Party shall commit any breach of or default in any of the terms or conditions of this Agreement, and also shall fail to remedy such default or breach within ninety (90) days after receipt of written notice thereof from the other Party hereto, the Party giving notice may, at its option and in addition to any other remedies which it may have at law or in equity, terminate this Agreement by sending notice of termination in writing to the other Party to such effect, and such termination shall be effective as of the date of the receipt of such notice. The defaulting Party shall be responsible for all costs and expenses associated with the termination, and shall reimburse the non-defaulting Party for such.

XIII. ARBITRATION

In the event of a dispute hereunder that involves the sum of Sixty-Five Thousand Dollars ($65,000) or less, in money damages only, exclusive of interest, costs and attorneys’ fees, the Parties will submit the matter to arbitration if required under A.R.S. § 12-1501, et. seq.

XIV. CONFLICT OF INTEREST

This Agreement is subject to the provisions of A.R.S. § 38-511 regarding Conflict of Interest.

Either ASU or ACDHH may cancel this Agreement if any person significantly involved in negotiating, drafting, securing or obtaining this Agreement for or on behalf of the Arizona Board of Regents or ACDHH becomes an employee in any capacity of any other Party or a consultant to any other Party with reference to the subject matter of this Agreement while the Agreement or any extension thereof is in effect.

XV. STATE OBLIGATION

The Parties recognize that the performance by both parties may be dependent upon the appropriation of funds by the State Legislature of Arizona. Should the Legislature fail to appropriate the necessary funds or if ACDHH’s is reduced during the fiscal year, ACDHH or ASU may reduce the scope of the Agreement or cancel the Agreement without further duty or obligation. The Party with the insufficient appropriation agrees to notify the other Party as soon as reasonably possible after the unavailability of said funds comes to their attention.

XVI. NOTICES

Notices shall be in writing and deemed effective when sent, postage prepaid to:

ACDHH

Carlos Castillo Business Manager Arizona Commission for the Deaf and the Hard of Hearing 100 N. 15th Avenue, Suite 104

602-542-3857 (voice) C.Castillo@acdhh.az.gov

With a copy to:

Dr. Kristin Samuelson

ASU

XVII. GENERAL PROVISIONS

a. Compliance

The Parties agree to comply with the provisions of applicable State and Federal statutes, regulations, and executive orders governing Equal Employment Opportunity and Non-discrimination and Immigration including, but not limited to, Executive Order 2009-09, E- Verify requirements, and the Federal Immigration and Nationality Act.

b. Non-competition

This Project shall not involve competition with local business units that generally offer similar goods and services.

c. Independence

Permission to use ASU facilities and other resources under this Agreement does not constitute endorsement by ASU of the ACDHH's views or objectives.

d. Audit

In accordance with A.R.S. §§ 35-214 and 35-215, ASU shall retain all data, books, and other records (“Records”) relating to this Agreement for a period of five years after completion of the Agreement. All records shall be open for inspection and audit by ACDHH at reasonable times. It is understood that if the ultimate source of at least a portion of the ACDHH's funds for this Project is Federal, this Agreement is also subject to Federal Audit.

e. Third Party Antitrust Violations.

ASU assigns to the State any claim for overcharges resulting from antitrust violations to the extent that those violations concern materials or services supplied by third parties to ASU for or toward the fulfillment of this Agreement.

f. Entire Understanding

This Agreement embodies the entire understanding of the Parties and supersedes any other agreement or understanding between the Parties relating to the subject matter hereof.

g. Waiver, Amendment, Modification

No waiver, amendment or modification of this Agreement shall be valid or binding unless written and signed by the Parties. Waiver by either Party of any breach or default of any clause of this Agreement by the other Party shall not operate as a waiver of any previous or future default or breach of the same or different clause of this Agreement.

mailto:C.Humphries@acdhh.az.gov

h. Assignment This Agreement may not be assigned by either Party without the prior written consent of the other Party, which consent will not be unreasonably withheld; provided that this Agreement shall be binding upon and inure to each Party’s respective successors in interest.

i. Choice of Law

This Agreement shall be interpreted pursuant to the laws of the State of Arizona.

j. Severability If any provision of this Agreement is held void or unenforceable, the remaining provisions shall nevertheless be effective, the intent being to effectuate this Agreement to the fullest extent possible.

k. Independent Contractors

The Parties are deemed independent contractors and may not bind the other, except as provided for herein or authorized in writing by the other Party.

ARIZONA BOARD OF REGENTS, a body corporate, for and on behalf of

ARIZONA STATE UNIVERSITY COLLEGE OF HEALTH SOLUTIONS

By: Date: 5/5/2021 Provost

ACDHH:

By: Date:

(ACDHH Deputy Director, Carmen Green Smith)

By: Date:

(Authorized ACDHH Signatory, Business Manager, Carlos Castillo)

Exhibits:

A. Scope of Work B. Budget C. Application

5/13/2021

5/13/2021

EXHIBIT A

SCOPE OF WORK

1.1 ACDHH Mission Statement

1.2 ACDHH Mission: To ensure, in partnership with the public and private sectors, accessibility for the deaf, hard of hearing, deafblind, and persons with speech difficulties, to improve their quality of life.

2.1 Purpose

2.2 Purpose Statement: This agreement’s purpose is to provide a variety of Hearing Healthcare Services to low income adults (aged 21+), referred to ASU CHS

- SHC by ACDHH, who have, or are suspected to have, a hearing loss that could benefit from amplification for the purpose of understanding speech. The ACDHH, through the Hearing Healthcare Program and as listed in this agreement, will reimburse ASU- SHC for costs associated with providing Hearing Healthcare Services to low- income adult Arizona residents who meet the criteria established by ACDHH. The hearing loss under this agreement will be unilateral or bilateral, and must average between a minimum of 40 dBHL and up to 80 dBHL, in the frequency range of 500 Hz to 4000 kHz. Hearing Healthcare Services will enable adult Arizonans to optimize and enhance their ability to hear and understand speech on the telephone and in other situations, including accessing Arizona Relay Services, and will improve their quality of life.

2.3 Legal Authority:

ACDHH is authorized to enter into this Agreement pursuant to A.R.S. § 36- 1943(A) (Providing “[w]ith the approval of the commission, the executive director may contract for professional, technical and clerical services necessary to carry out functions of the commission”). Pursuant to A.R.S. §§ 36-1944, 1943, ACDHH mission and duties encompass the study of issues related to the deaf and the hard of hearing; the review, administration and operation of programs; the review of the need for effective communication involving the deaf and hard of hearing community; the study of appropriate auxiliary aids and acoustical devices, and advocacy for the provision of these services.

2.4 Projected Utilization: The purchase of these services will be on an as-needed basis and there is no guarantee of the number of services to be purchased.

2.5 Projected Awards and Timeline:

2.5.1 ACDHH intends to make multiple payments to ASU CHS - SHC for Hearing Healthcare Services provided to persons referred by ACDHH to

ASU CHS - SHC.

2.5.2 The anticipated start date is May 1, 2021.

2.5.3 ACDHH and ASU anticipate that this Project will continue while resources

(hearing aids, staff, funding) are available.

2.4.4. The Project will have up to 5 phases: (1) Hearing Test, (2) Fitting, (3) Adjustment/Follow up #1 and #2, (4) Aural Rehabilitation, and (5) Ongoing Analysis and Reporting.

3.1 Service Description and Requirements

3.2 Taxonomy Definition: Audiology Assessment is a service that utilizes a variety of audiological evaluations to determine if an individual has hearing deficiencies that may benefit from correction, action and/or treatment. For the purpose of this agreement, Audiology Assessment includes the following:

1. Diagnostic Audiology Evaluation to determine the type, magnitude, and configuration of hearing loss, including making ear impression(s)/mold(s).

2. Providing hearing aid(s) at no cost to ACDHH or the Recipient with:

a) manual telecoil(s) whenever possible, and,

b) data logging whenever possible, and,

c) if possible, Bluetooth.

3. Hearing Aid(s) Fitting & Adjustment, Follow Up Services, Dome(s), Batteries, Wax Traps, Training on the HA(s) technology.

4. Aural Rehabilitation instruction, one-on-one and/or group.

3.3 Service Requirements: Provide Audiology Assessment services as follows:

1) Schedule a meeting with the Applicant and provide Audiology Evaluation within ten (10) business days upon receipt of an emailed ACDHH authorization.

2) Provide comprehensive Audiology Evaluation to include:

1. Audiometry threshold and speech recognition,

2. Tympanometry

3. Acoustic reflex testing,

4. Speech-in-noise testing,

5. Otoscopy for appropriate audiology management or as a basis for medical referral to specialty physicians,

6. Cerumen management to prevent obstruction of the external ear canal and of amplification devices.

3) If Client has a hearing loss that could benefit from amplification for the purpose of understanding speech, make ear mold(s) or impression(s) of the outer ear or ear canal during the audiology evaluation, if ear molds are needed. Ear molds or impressions shall be ordered by ASU CHS - SHC and reimbursed by ACDHH, but not exceeding the maximum listed in this ISA (see

6.8 ACDHH fee schedule).

4) Provide hearing aid fitting and follow up services as follows:

a) For hearing aid(s) with dome(s): Fit the hearing aid(s) at the time of the audiology evaluation and schedule two (2) follow up appointments to occur within 45 days of dispensing.

b) For hearing aid(s) with mold(s): Fit the hearing aid(s) upon receipt of the mold(s) and schedule two (2) follow up appointments to occur within 45 days of dispensing.

c) Provide domes, wax traps, and batteries as needed, but not exceeding the maximum listed in this ISA.

5) Ensure that hearing aid(s) fitting and follow up services include the following:

1. Electro-acoustic analysis for quality control to verify functioning, and

2. Electro-acoustic verification (coupler or real ear) to ensure proper programming of aided sound field thresholds, and

3. Aided speech measures (in quiet and in noise), and

4. Outcome measures, pre and post fitting, such as Abbreviated Profile of

Hearing Aid Benefit (APHAB), Client Oriented Scale of Improvement (COSI) or Performance Inventory for Profound and Severe Loss (PIPSL), and

5. Hearing aid orientation and counseling to include instructions and demonstration regarding the utilization and benefits of a telecoil, cleaning and maintaining of hearing aids, and any other relevant information; assisting the Recipient with any added technology (Bluetooth, MFI, MFA) that is included on the hearing aid, and

6. The additional technology (Bluetooth, MFI, MFA) must be activated and the Recipient must receive instructional information that helps them configure the technology so that it connects with the Recipient’s Smartphone or Bluetooth enabled cell phone.

6) Aural Rehabilitation: The hearing aid Recipient is not required to attend aural rehabilitation individual sessions or group sessions, however they will be encouraged to attend; attendance may occur at any time before June 30, 2021. Aural rehabilitation helps the hearing aid Recipient improve their quality of life by learning more about their hearing loss, assistive technology, communication strategies, accommodations, self-advocacy, and the hearing aid itself.

7) ASU CHS - SHC also conducts research into hearing loss and hearing aids, as such the Recipient will also be offered the opportunity, but not required, to participate in ASU research, with or without compensation from ASU CHS - SHC, and without any compensation from ACDHH.

4.1 Other Service Requirements; ASU CHS - SHC shall:

4.2 Comply with all applicable federal, state and local laws and regulations as they pertain to services under this contract.

4.3 Be licensed to fit and adjust hearing aid technology in the state of Arizona for the duration of the contract.

1. Ensure that its personnel or subcontractors who provide audiology evaluation services are Audiologists licensed by the Arizona Department of Health Services (DHS) Division of Licensing Services Special Licensing Team in accordance with the Arizona Revised Statute§ 36-1901 et seq., and allowed to practice audiology and engage in dispensing hearing aids;

2. Maintain active professional license(s) that is in compliance with all federal, state, and local licensing requirements for the operation of its business or profession to include an audiology license and a dispensing audiology license, which allows the holder to fit and dispense hearing aids; and is in good standing with all applicable licensing and regulatory boards or agencies. For the purpose of this contract, "good standing" means that no disciplinary actions have been taken by any licensing or regulatory agency to include, but not limited to: cancellation with cause, civil penalty, decree of censure, inactive with cause, letter of reprimand, practice restriction, probation, revocation, summary suspension, surrender of licenses, suspension, etc.

3. Inform ACDHH by formal written notification within five (5) business days if there are any actions from any of the applicable Arizona licensing and regulatory boards or agencies which may result in disciplinary action taken on their current licensure.

Administrative Requirements

4. Maintain equipment used in the practice of audiology according to the manufacturer's specifications. If the equipment requires calibration, ASU shall ensure that calibration is made in accordance with the Arizona Administrative Code R9-16-209 "Equipment;

Records; Inspections" which requires that:

The equipment is calibrated a minimum of every twelve (12) months according to the American National Standard - Specifications for Audiometers, S3.6-1996, Standards Secretariat, c/o Acoustical Society of America, 120 Wall Street, 32nd Floor, New York, New York 10005-3993, January 12, 1996, incorporated by reference and on file with the Department and the Office of the Secretary of State. This incorporation by reference contains no future additions or amendments. A written record of the calibration is maintained in the same location as the calibrated equipment for 36 months from the date of the calibration.

4.4 Repair, within the period covered by this agreement, and at no cost to ACDHH, any hearing aid(s) not functioning while under warranty.

4.5 Deliver services either directly at ASU CHS - SHC or via teleaudiology per this contract.

4.6 Provide the following documents to each Recipient at the fitting:

1. A bill of sale that lists the hearing aid(s) serial number(s), brand and model.

2. User Guides, Warranty(s), and other documentation relevant to the usage of the product.

3. A copy of the Recipient’s audiogram at no charge.

4.7 Allow a return policy, up to forty-five (45) calendar days from day of dispensing, to allow for trial of hearing aids by the Recipient. ASU CHS - SHC shall accept the return of the hearing aid(s) at any time during the forty-five (45) day trial period, if the Recipient is unsatisfied with the hearing aid. ASU CHS - SHC will report to ACDHH the return of a hearing aid including any that have been altered, tampered with, misused, or abused and the name of the Recipient. If the hearing aid needs to be serviced at any time during the forty-five (45) day trial period and the Recipient is without the hearing aid, the trial period is paused until the Recipient is in possession of the hearing aid again.

Technical Support:

A. Provide technical support to Recipients regarding product features and compatibilities via telephone, internet, in-person, and by e-mail as requested by Recipients or ACDHH.

B. Ensure that technical support via telephone, website, and written documentation and or by mail is accessible to individuals with disabilities.

Product Warranty:

A. Provide the maximum warranty at no additional cost on all products and associated components which shall not be less than one (1) year warranty for repair and loss/damage or comparable.

B. The warranty shall begin on the date the product is dispensed to the Recipient by the licensed Audiologist.

Product Repair:

A. Provide a method of operation and a physical location address for all warranty repair work.

Foreign Language and Limited English Proficiency:

A. ASU CHS - SHC shall ensure that all services provided are culturally relevant and linguistically appropriate to the population served.

B. Communicate, either directly or through assistance, in the native language of persons who have limited speaking ability or for whom

English is not their primary language, and use all other appropriate and effective modes of communications used by such persons.

C. Make reasonable accommodations under the Americans with Disabilities Act of 1990, as amended, to give people with disabilities an equal opportunity to benefit from programs, services, and activities.

5.1. Procedure for Ordering and Providing Services

A. A Consumer contacts ACDHH for hearing aid services. Consumers who meet the initial qualifications will be referred to ASU CHS - SHC and become Applicants. Consumers who do not meet the initial qualifications will be provided with information and referral to other programs and providers by ACDHH.

B. ASU CHS - SHC will contact the Applicant within 10 business days of receiving the ACDHH referral and will make at least 2 attempts to schedule an appointment for a hearing test.

C. ASU CHS - SHC will test the Applicant’s hearing; or at their discretion accept a hearing test obtained with the past 12 months;

D. If the Applicant’s hearing loss per ear averages between a minimum of 40 dBHL and up to 80 dBHL, in the frequency range of 500 Hz to 4000 kHz, the Client will be provided with hearing aid(s) and other services as delineated on this agreement as needed.

E. If the Applicant’s hearing loss per ear averages less than 40 dBHL or greater than 80 dBHL, the Applicant will be referred back to ACDHH for consumer information and referral.

F. ASU CHS - SHC will provide detailed information to the ACDHH Hearing

Healthcare Program representative(s) regarding all services provided under this

ISA.

G. ASU CHS - SHC will submit invoices to the ACDHH Financial Services Unit

(Carlos Castillo or his designee) within thirty (30) days for services provided to persons referred by ACDHH with a copy to Michele Michaels at ACDHH.

H. ASU CHS - SHC will keep on file the Bill of Sale, hearing test, list and number of items dispensed (domes, wax traps, batteries) and notes about fitting, adjustment, training, and attendance at aural rehabilitation individual sessions or group sessions.

I. Nothing in this scope of work precludes ASU from offering, with or without a fee, additional follow up appointments, services, warranties, hearing aid accessories, and assistive devices beyond the services reimbursed by ACDHH.

5. 2 Subcontracting: ASU CHS - SHC shall not subcontract any of the work contemplated under this Contract.

5. 3 A Note on Terminology:

● A Consumer is a person who contacts ACDHH and requests Hearing Healthcare Services. If they meet the ACDHH Project screening criteria and submit an application with complete documentation, they become an Applicant.

● An Applicant is a person referred to ASU CHS - SHC for a hearing test.

● An Applicant who receives a hearing test from ASU CHS - SHC shall be called a Client.

● A Client whose hearing test results fit within the criteria defined in this ISA and who receives hearing aid(s) will thereafter be called a Recipient.

● A Client whose hearing test results do not fit within the criteria defined in this ISA shall be referred back to ACDHH and thereafter be called a Consumer.

6.1. PAYMENT

6.2. The price for the services will be as noted.

6.3. Prices for services shall include all administrative and overhead costs.

6.4. Payment will be made by ACDHH upon receipt and acceptance of a complete and accurate invoice.

6.5. Payment rates are all inclusive, which means they include ASU CHS - SHC’s staff time, administrative cost, research, report preparation, time lost due to client missed appointment(s) (“no shows”), shipping costs, and other costs associated with the service provision.

6.6. Payment for Audiology Assessment can include testing, making ear molds or ear impressions, batteries, domes, wax traps, fitting, adjustment, and aural rehabilitation.

Exclusions: This contract specifically excludes payment for the purchase of hearing aid(s), shipping, warranty or insurance for HA(s), Communication Access Realtime Translation (CART) and travel. All hearing aids will come from previous donations already received by ASU CHS-SHC. No cost will be incurred by either ASU CHS-SHC or ACDHH for hearing aids.

6.7. ACDHH Fee Schedule:

Service Provided: Amount:

1. Hearing test $40 one time only per year

2. Hearing aid fitting and 2 follow ups, 1 or 2 HA $175 total per year

3. Ear mold, each, if needed $50 each, 1 per ear per year

4. Hearing aid batteries, 6 per pack $6 per pack, maximum 9 packs per HA per year

5. Wax traps, 6-8 per pack $6 per pack, maximum 4 packs per HA per year

6. Domes, 8-10 per pack $6 per pack, maximum 1 pack per HA per year

7. Aural Rehabilitation, One-to-One, 3 hours per year, or Group, 4.5 hours per year

$200 per year

8. Aural Rehabilitation, print materials $20 one time only

7.1 Reporting Requirements

7.2 ASU CHS - SHC will:

1. Submit a copy of the Bill of Sale as signed by Recipient to the Hearing Healthcare Program at ACDHH

2. Make sincere attempts to reach Recipients to encourage them to return for follow up appointments

3. Survey Recipients as to their level of satisfaction with the services received from ASU CHS - SHC

4. Provide copies of completed satisfaction surveys to ACDHH

5. Submit an invoice to ACDHH within thirty (30) days, attention Carlos

Castillo, Business Manager, for services provided under this Scope of Work, with a copy to Michele Michaels.

7.3 In the event of business closure: ASU CHS - SHC shall immediately notify ACDHH’s Contract Administrator of such transaction. ASU CHS - SHC must present to ACDHH’s Contract Administrator the following information within thirty (30) days of the transaction date:

1. Effective date of closure

2. A list of ACDHH Recipients tested and/or fitted within a year prior to closure

3. A plan of action stating how ACDHH Recipients will receive services and follow ups

7.4 Invoices: ASU CHS - SHC shall submit invoices to the following:

Carlos Castillo Business Manager ACDHH 100 N. 15th Ave, Suite 104

C.Castillo@acdhh.az.gov

With a copy to:

Michele Michaels Hearing Healthcare Program Manager, ACDHH 100 N. 15th Ave., Suite 104

M.Michaels@acdhh.az.gov

7.4.1 The invoice shall, at a minimum, contain the following:

1. Invoice date,

2. ASU CHS - SHC name and address,

3. ASU CHS - SHC remit to address,

4. FEI Number,

5. Contract Number,

6. Applicant/Client/Recipient name, detailed list of services provided, cost of each service, date provided, and the total amount billed for each service

7. Name, title, telephone number and address of ASU CHS - SHC’s designated person to be notified in the event of a discrepancy on the invoice;

mailto:M.Michaels@acdhh.az.gov

ACDHH shall pay no more than the maximum amounts as listed in this agreement.

7.5 Other Reports

ACDHH reserves the right to request ASU CHS - SHC to submit additional or revised reports related to the service provision and contract performance.

Reporting requirements may change during the contract term. ASU CHS - SHC will be notified in writing about any change in reporting forms.

8.0 Definitions

ACDHH: The Arizona Commission for the Deaf and the Hard of Hearing

Applicant: A consumer who applies to ACDHH for Hearing Healthcare Services and is subsequently referred to ASU CHS - SHC for a hearing test under this agreement. This person shall be an adult:

✔ who is aged 21 or older, and ✔ who is a full-time resident of Arizona, and ✔ who is legally in the United States, and ✔ who is low-income (maximum of 133% of FPL), and ✔ who does not have the financial ability to acquire hearing aid(s), and ✔ who cannot receive hearing aid(s) from any other federal or state program (such as the VA, Indian Health Service, or AZ RSA), due to ineligibility or a wait list in excess of 12 months, and

✔ who does not have or is not covered by any insurance that provides coverage for the full cost of basic hearing aid(s), and

✔ who believes they would benefit from a hearing aid or hearing aids, and ✔ and who submits a complete application and supporting documentation to ACDHH for Hearing Healthcare Services.

✔ who does not currently have hearing aids less than 5 years old

ASU CHS - SHC: Arizona State University, Speech and Hearing Clinic

Audiogram: A complete audiogram indicates hearing thresholds for the right and left ear. It includes air conductors and bone conductors. It is also a graph that shows the audible threshold for standardized frequencies as measured by an audiometer.

Audiology Assessment: A service that utilizes a variety of audiological evaluations to determine if an individual has hearing deficiencies that may benefit from correction, action and/or treatment, as listed in 3.2.

Audiology Evaluation: A hearing test.

Aural Rehabilitation: Provided 1:1 or in a group, aural rehabilitation is intended to help the individual adjust to amplification, learn communication strategies and self-advocacy skills. Communication partners are also involved in the program to develop strategies to support the individual with hearing loss at home.

Batteries: Batteries provide the power supply for hearing aids.

Bluetooth: Wireless communication platform that uses high frequency radio waves to transmit data from mobile phones, phone hubs, and tablets to a hearing aid. Intermediary devices such as Bluetooth phone streamers may be needed.

Client: An Applicant who receives a hearing test from ASU CHS - SHC under this agreement.

Consumer: A person who contacts ACDHH and requests Hearing Healthcare Services.

Data Logging: Information stored in the hearing aid about hours of use and programs being used.

dBHL: Decibels hearing level. (i.e. dB is relative to the quietest sounds that a young healthy individual ought to be able to hear).

Dome: A disposable silicone tip placed on the receiver portion of the hearing aid in the ear canal. It provides retention of the receiver in the ear canal and ensures that sound from the hearing aid is directed to the ear canal.

Ear Mold/mold: A piece of plastic or other soft material molded in different occluded or non-occluded styles to fit in the ear and to deliver the sound from a BTE hearing aid.

Hearing Aid(s): an acoustic or digital device

Hearing Healthcare Services: Any services listed in this agreement.

Recipient: A Client who receives a hearing aid or hearing aids and any other related services, with the exception of a hearing test, under this agreement.

Resident: A person who resides full-time in Arizona for 12 months of the year.

Telecoil: Sometimes called “Telephone Coils” or “T-coils”, are electronic devices that allow audio sources to be directly connected to hearing aids. Telecoils help hearing aids filter out background noise. They can be used with telephones, FM systems, induction loop systems, and public address systems. A telecoil-equipped hearing aid assists a person with accessing relay services.

Wax Trap: A gauze tip fitted on the receiver/ear mold to prevent cerumen from clogging the receiver of the hearing aid.

EXHIBIT B

BUDGET AND SCHEDULE OF PAYMENTS

ASU CHS - SHC is able to complete all phases of the proposed Project for a fixed rate price of no more than $100,000.00 per fiscal year as follows:

Service Provided: Amount:

1. Hearing test $40 one time only per year

2. Hearing aid fitting and 2 follow ups, 1 or 2 HA $175 total per year

3. Ear mold, each, if needed $50 each, 1 per ear per year

4. Hearing aid batteries, 6 per pack $6 per pack, maximum 9 packs per HA per year

5. Wax traps, 6-8 per pack $6 per pack, maximum 4 packs per HA per year

6. Domes, 8-10 per pack $6 per pack, maximum 1 pack per HA per year

7. Aural Rehabilitation, One-to-One, 3 hours per year, or Group, 4.5 hours per year

$200 per year

8. Aural Rehabilitation, print materials $20 one time only

The total amount above does not include the following expenses:

(1) Hearing aid(s)

(2) Shipping costs

(3) Warranty or insurance for loss or damage of Hearing aid(s)

(4) Travel by ASU staff, students, clients, or recipients

(5) Foreign language translation

(6) Communication Access Realtime Translation (CART)

EXHIBIT C

Applicant Number: _________________

Arizona Commission for the Deaf and the Hard of Hearing

Hearing Healthcare Assistance Project

Application, May 2021

Name Age Date of Birth

Gender Marital Status

Address City Zip

County Full-time Resident of Arizona since:

Email address: Work phone

Home phone Cell phone

Emergency Contact Name, Phone Number, Relationship

How did you hear about us?

Do you have difficulty hearing? If so, which ear or ears?

How long have you had difficulty hearing? Do you have difficulty hearing on the phone?

Do you now, or have you ever, worn hearing aid(s)?

If yes, from whom and where did you receive hearing aids:

If yes, when did you receive the hearing aids? Who paid for them?

How would hearing aid(s) assist you in improving your quality of life?

Are you a working adult? Are you retired?

Are you an enrolled member of a Native American Indian tribe, if so, which?

Are you a veteran or active duty military?

Do you have health insurance, if so, company and plan:

Do you have Medicare Advantage, if so, company and plan:

Screening Questions

Contact and Personal Information

Hearing Questions

Have you checked with the above programs to see if they can provide you with hearing aids and other hearing healthcare services? If so, what did they say?

To be eligible for a hearing test through the ACDHH Hearing Healthcare Assistance Project, the Applicant must meet the following criteria:

✔ You must reside legally in the United States, and ✔ be a full-time resident of Arizona for 12 months of each year, and ✔ be aged 21 or older, and ✔ your total household income must be equal to or less than 133% of the current Federal Poverty Level (FPL).

To be eligible for hearing aid(s) through the ACDHH Hearing Healthcare Assistance Project, the Applicant must meet the following additional criteria:

✔ your hearing loss must be at a level that would benefit from hearing aid(s) in order to understand speech, use the telephone, and access relay services.

This Project is the payor of last resort. You must utilize any other resource that pays for the full cost of hearing healthcare services before being eligible for this Project.

If you qualify for this Project, ACDHH will send a referral to the Arizona State University (ASU) Speech and Hearing Clinic (SHC) on the Tempe campus for a hearing test for you. ASU SHC staff will contact you to schedule your hearing test. You must visit the ASU campus in Tempe for the hearing test and any related services. If you are unable to visit the Tempe campus, you will not receive services under this Project. There is no cost to you for any of the hearing healthcare services provided under this Project.

Total Number of Persons in Household:

Type of Income Amount Gross wages, salary, tips $

Self-employment income $ Social Security, SSI, and/or SSDI $

Pensions $ Public Assistance $

Unemployment or Workers Comp $

TOTAL $

If I am provided with hearing aid(s) under this Project, I agree:

⮚ To be responsible for the daily care and maintenance of the hearing aid(s), and ⮚ To not alter, tamper with, misuse, or abuse the hearing aid(s), and ⮚ To not give away or sell the hearing aid(s) and to return them to ASU SHC when no longer needed, and ⮚ To be responsible for the cost of replacement ear mold(s), if needed, past the 45 day trial period, and

I hereby attest and affirm with my signature below that all of the information on this application and submitted with this application is complete, accurate, and truthful, and I agree to the conditions set forth above.

Eligibility

Income Totals for All Persons in the Household

Attestation and Signature

Signature of Applicant Date

Return this completed form with photocopies of supporting documentation to: Ms. Christy Abrams, Hard of Hearing Specialist, ACDHH, 100 N. 15th Ave. Suite 104, Phoenix, AZ 85007 C.Abrams@acdhh.az.gov, 602-542-1124.

To determine eligibility, ACDHH must receive a complete application with supporting documentation.

Incomplete applications will be held for 2 months and then destroyed.

mailto:C.Abrams@acdhh.az.gov