Special Contract Provisions_Attachments BF-BK (HDM).pdf

ATTACHMENT BF

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996

The department and the recipient will comply with all requirements of the Health Insurance Portability and

Accountability Act (HIPAA) of 1996. The department and the recipient recognize that each is a "Business

Associate" of the other under the terms of HIPAA. As such, each agrees to the following:

(a) That neither party will use or disclose protected health information for any purpose other than as authorized by law, by this contract, or by separate agreement between the parties.

(b) That each party will not use or disclose protected health information in a manner which would be a prohibited use or disclosure if made by the other.

(c) That each party will maintain safeguards as necessary to ensure that the protected health information is not used or disclosed except as provided by law, by this contract, or by separate agreement between the parties.

(d) That each party will report to the other any use or disclosure of the protected health information of which it becomes aware that is not provided for by law, by this contract, or by separate agreement between the parties.

(e) That each party will ensure that any of its subcontractors or agents to whom it provides protected health information received from the other agree to the same restrictions and conditions that apply to each other with respect to such information.

(f) That each party will follow an agreed upon process established to provide access to protected health information to the subject of that information when the other has made any material alteration to the information. This process will include how each party would determine in advance how the other would know or could readily ascertain when a particular individual's protected health information has been materially altered by the other and how it could provide access to such information. This process will establish how each party would provide access to protected health information to the subject of the information in circumstances where the information is being held by the other.

(g) That each party will provide health information to the subject of the information in accordance with the subject's right to access, inspect, copy, and amend their health information.

(h) That each party will make available to the other its internal practices, books and records relating to the use, disclosure, and tracking of disclosure of protected health information received from the other or its agents for the purposes of enforcing compliance with HIPAA.

(i) That each party will assist the other in meeting its obligation to provide, at an individual's request, an accounting of all uses and disclosures of personal health information which are not related to treatment, payment, or operations within 60 days of the request of an accounting.

(j) That each party will incorporate any amendments or corrections to protected health information when notified by the other that the information is inaccurate or incomplete.

(k) That at the termination of this contract, unless a new contract is agreed upon, each party will return or destroy all protected health information received from the other that it still maintains in any form.

(l) That either party may terminate this contract if it learns that the other has repeatedly violated a term of this contract provision.

ATTACHMENT BF

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) OF 1996 (Cont’d)

(m) That each party will disclose only the minimum amount of information necessary to accomplish the permitted use of the protected health information. This minimum use requirement does not apply to information provided for treatment or to disclosures required by law.

(n) That each party will limit the use and disclosure of protected health information to the minimum number of employees necessary by class of employee and type of information to accomplish the permitted use of the information.

(o) That each party will meet at least the minimum security requirements for the protection of protected health information as required by HIPAA.

(p) That each party is bound by the terms of the "Notice of Practices" of the other with regard to protected health information it receives from the other.

PROVIDER'S C BG

s

Provider's State Contract List

PROVIDER INFORMATION:

Name:

llddress:

FEJO:

Phone:

Email:

Cm ta cl:

REPORT PERICO:

From: ___ _

To: ----

I Contract /1 I Contract/ I State Agency/ I Start I End I Description of Contract I Contract I Phone /1 I Contract

Program Name Program Date Date Purpose/ Types of Seiv1ces Manager Amount

SIGNATURE: -------

TITLE: --------

I

T

DATE:-----

Total ----

Revised April 2017

ATTACHMENT BH

MANAGEMENT ATTESTATION LETTER

(To be completed at the end of provider’s or sub-provider’s fiscal year)

Contract or Agreement Number:

I, _____________________________________________, hereby attest under penalty of perjury (provider’s/sub-provider’s authorized representative) that ___________________________________________, based on the criteria (provider/sub-provider agency name) set forth in the Agency Audit Attachment, PARTS I and II, that:

A. The above name provider agency is not required to provide an audit report or reporting package because [check applicable statement(s)]:

The above-named entity has not expended $500,000 or more in total federal awards in its fiscal year and therefore, is not required to have a single or program-specific audit performed in accordance with OMB Circular A-133, as revised, and/or;

The above-named entity has not expended a total amount equal to or in excess of $500,000 in state awards in its fiscal year and therefore, is not required to have a State single or program-specific audit in accordance with section 215.97, Florida Statutes.

B. The provider/sub-provider has complied with the allowable cost provision [congruent with State and Federal law, generally accepted accounting principles, the Department of Financial Services’ Reference Guide for State Expenditures, and Office of Management and Budget (OMB) Cost Principles 225 (A-87, 230 (A-122) and Federal Acquisition Regulation 31.2 or Part 215 (formerly OMB A-110), whichever is applicable].

By making this statement, the provider/sub-provider has considered not only funding or awards from the Agency, but all sources of Federal and State funding or awards.

Fiscal year ended ______________________.

(Month, Day, Year)

(Signature)

(Title)

(Date)

WNU***VENDOR/AGENCY

265*** Ex. John Smith Ex. 4321 Ivory Way Lake Worth, FL 33463

561-694-23**

355-47**_________

10/25/1945

ATTACHMENT BI

ATTACHMENT BJ

Palm Beach County Division of Senior Services

Conlidcntinlity Statement

Statement from Pnlm Dench County Division of Senior Services:

All staff/subcontractors/vendors that arc working directly or indirectly with Palm Beach County Division of Senior Services clients must read nnd sign this form.

As a provider of Case Management, Adult Day Care, Nutrition and Senior Center's, Pnlm Beach County's Division of Senior Services (DOSS) receives and utilizes personal heulth information relating to the clients of the Senior Services Division. Personal health information can be in any fomrnt, including written, electronic, and oral. A federal law known as the Health Insurance Portability and Accountnbility Act of 1998 (HIPAA) protests the confidentiality of such personal health information.

!!' in your role with Palm Beach County you :trc not autliorlzcd to have access to this personal health information, however, you may inndvcrtcntly receive \vritten, elcclronic, and oral such confidential personal health information; you must immediately report it to DOSS's HIPAA Compliance Officer at (561) 355- 4753 or to the County's HIPAA Privacy Officer nt (561) 355-4019.

You must maintain the confidentiality of such informntion and not further disclose or repeat the infonnation. If there is a document or package involved, it should be handled in nccordancc with the direction of the HIPAJ\ Compliance Officer or the HIP/\/\ Privacy Officer.

Tlrnnk you for your assistance in the matter .

(Print Nainc) undcrstnnd ~nd acknowledge that I have read th6 information above in rcfcren9e to Palm Beach County's policies conccrnii1g personal health itiformation .. I undcrstnnd and aclrnowledgc nty rcsponslbjllty to Palm Bench County Division of Senior Services ·to iinmedlntciy report ifl receive; ~ce or· fiear persoiuil'health Information that I em not authorized to receive. I also understm1d that uirnuthorized use or disclostlro of PHI will result in disciplinary action, including the imposition of civil penalties and criminal penalties under applicable federal and state law.

Name (I'rint): -------------------------------

Agency Name:--------------------------------

Department: ________________________________ _

Job Title:-------------------------------

Signature:---------------------------------

Date:~~~---~~-~~~~~-----~----~---------~

ATTACHMENT BK

BILLING PROCEDURES

Successful vendor shall be required to adhere to the following billing/invoice procedures:

A. Billing/invoices shall be submitted electronically on a bi-weekly basis via the Palm Beach County Board of County Commissioners Vendor Portal website. Statements shall cover the services provided two weeks prior (Monday through Sunday), with the exception of grant and County fiscal year end, and shall be received no later than 5:00 p.m., on Thursdays. At OAA and CCE/ADI/HCE grant year end (December 31 and June 30, respectively), all invoices for services rendered prior to grant year end must be submitted within fourteen (14) days after the grant year ends (January 14 - OAA/July 14 - CCE, ADI & HCE/October 14 - PBCC,PBC90, PBS & PBR). Late billing shall be approved for payment at the discretion of the Department. No payment shall be made for any invoices submitted after this fourteen (14) day period with the exception of items previously “Disallowed.”

Example: Monday October 2, 2018 to Sunday October 15, 2018 Invoice due October 19, 2018

B. Within one (1) month of contract initiation, all vendors must be prepared to deliver invoice data as required by Palm Beach County Division of Senior Services through the Palm Beach County Board of County Commissioners Vendor Portal website. After the initial first month, vendors must comply with the bi-weekly due dates listed herein.

C. For billing purposes, a Unit of Service is one (1) delivered meal of a meal type specified in the contract. Delivery sheets shall reflect actual meals delivered and signed for by the client.

D. Invoices:

1. Shall be submitted electronically through the County’s Vendor Portal website. Successful vendors shall have access to the secure Portal Website and shall receive a Training Manual. Training can be provided by Palm Beach County if needed prior to or at the start of the contract period. Successful vendor shall be responsible for training in-house staff once the initial training has been completed.

2. Shall be uniquely numbered and clearly identifiable. Date(s) and meals delivered shall be clearly identifiable/legible on the submitted delivery sheet. Cross-outs and/or changes that obstruct the reading of the delivery sheet may result in the disallowment of service(s). If a client’s Prescription is “active” and not on “hold,” and services have not been rendered, a zero (0) must be entered for the date and meal.

3. Shall not include gaps in meal deliveries. Meal Delivery Dates must be billed and submitted in chronological order.

4. Shall include delivery sheets that have been arranged in chronological order for the billing period, due to the vendor portal not allowing billing to be submitted that is out of chronological order.

5. Shall be created through the Vendor Portal and shall include the following information:

a. Client’s name (in alphabetical order)

b. Prescription number

c. Delivery sheet number

d. Date of service

e. Number of meals

f. Meal type

g. Cost per meal

h. Total cost for all meals

i. Total charge per invoice

ATTACHMENT BK

E. Delivery Sheets:

1. May accompany each Invoice, be completed/signed in ink and include the following information:

a. Client's name and signature legibly written.

b. Prescription number, number of meals and meal type delivered.

c. If a client is unable to sign his/her delivery sheet, the signature area must be marked with “Client

Unable to Sign.”

d. Name of agency providing the service and phone number.

2. Shall be clearly understood (without requiring image rotation) and entered into the Vendor Portal system.

3. Failure to obtain a client’s signature for proof of delivery may result in non-payment.

E. Late Billing/Disallowments:

1. Delivery sheet that are returned to the vendor for correction are considered disallowed and will not be paid until corrected and submitted in a timely manner. Disallowed billing must be resubmitted within fourteen (14) days of the original billing date of the disallowment except for disallowed billing at grant year-end. Any disallowed billing submitted in that timeframe must be resubmitted prior to the grant closeout date referenced herein.

Vendors will be notified one month in advance of the grant close out date. Any disallowed items submitted past this timeframe are subject to being disallowed due to late submission and may only be allowable and payable with Departmental approval.

4. All disallowed items resubmitted for payment shall be issued on a new invoice using a new unique Invoice

Number.

5. Successful vendor must be able to provide proof of delivery for any meals provided under this contract. Failure to provide this information may result in non-payment.

3. Late billings shall require approval for payment at the discretion of the department and should be submitted within fourteen (14) days of the billing due date. Late billing or failure to submit billing prior to the grant year-end may result in non-payment. All billing must be submitted within thirty (30) days of the contract year-end or may be subject to disallowment and/or non-payment.

F. Hold/Resume/Cancel:

1. Payment shall not be made on prescriptions that have been placed on hold or canceled and submitted electronically to the provider. Services that have been placed on hold shall not resume until the vendor has received notification electronically from the Division of Senior Services.

2. Successful vendor shall be asked to complete the DOSS FAX and/or E-MAIL Log as official notification of receipt of a Service Change Form for prescription holds, notifications to resume and/or cancellations. DOSS will not provide payment for services rendered beyond the prescription hold or cancel date.

G. Record Retention:

The successful vendor shall maintain original records of services (delivery orders/invoices/delivery sheets with original signature form client/caregiver) for at least six (6) years, and provide copies to the COUNTY when/if requested. The COUNTY shall have complete access to records and documents for the purpose of inspections and/or audits. Billing procedures may be subject to change and vendors shall be notified ahead of time in order to insure compliance with billing procedures. Failure to submit invoices as specified in billing procedures may result in non-payment of invoice(s).