YH19-0025_Amendment_14_.pdf_fully_Executed_2023.09.29.15.46.29.pdf

CONTRACT AMENDMENT

1. AMENDMENT #:

2. CONTRACT #:

YH19-0025

3. EFFECTIVE DATE OF AMENDMENT:

Upon CMS Approval

4. PROGRAM:

DHCM

5. CONTRACTOR/PROVIDER NAME AND ADDRESS:

Sandata Technologies 26 Harbor Park Drive

Port Washington, NY 11050

6. PURPOSE: The Enhancement Pool is not to exceed $500,000.00. The total contract value will be increased from $45,614,986.44 to $46,114,986.44

7. THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS:

A. The Parties hereby establish an Enhancement Pool:

1. The Enhancement Pool is not to exceed $500,000.00 through the end of the Contract including any optional extension periods. Funding is contingent on approved budgets and funding availability. The total five-year contract value will be increased from $45,614,986.44 to $46,114,986.44.

2. Funds in the Enhancement Pool may only be used for work to be performed on approved Change Requests (CRs).

3. CRs shall include requirements, scope, firm fixed price, milestone schedule, and acceptance criteria in the current change request template.

4. The State, through the Change Advisory Board (CAB) action, must approve in writing both the design, milestone schedule and firm fixed price prior to the state of development for system enhancements and any changes to the design, milestone schedule or firm fixed price that occur after the original approval.

5. Firm Fixed Pricing shall be based upon the reasonable number of staff hours required plus any other reasonable expenses needed to affect the change.

6. CRs shall be invoiced timely upon delivery of work as described in the approved CR.

8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR

AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.

IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT.

9. NAME OF CONTRACTOR/PROVIDER:

Sandata

10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE:

TYPED NAME:

Akshay Bhandari

TYPED NAME: Tracey Thomas, Procurement Manager on behalf of Meggan LaPorte, CPPO, MSW

TITLE:

CFO

TITLE:

Chief Procurement Officer

DATE: DATE:

DocuSign Envelope ID: 8AB984A5-1F6F-47E7-87BE-FE440A549859

9/29/2023 9/29/2023

Certificate Of Completion Envelope Id: 8AB984A51F6F47E787BEFE440A549859 Status: Completed

Subject: Please DocuSign This Document

Source Envelope:

Document Pages: 1 Signatures: 2 Envelope Originator:

Certificate Pages: 6 Initials: 0 Lisa Monreal

AutoNav: Enabled

EnvelopeId Stamping: Enabled

Time Zone: (UTC-07:00) Arizona

801 E. Jefferson St.

Phoenix, AZ 85034

Lisa.Monreal@azahcccs.gov

IP Address: 64.207.219.71

Record Tracking Status: Original

9/29/2023 3:26:12 PM

Holder: Lisa Monreal

Lisa.Monreal@azahcccs.gov

Location: DocuSign

Security Appliance Status: Connected Pool: StateLocal

Storage Appliance Status: Connected Pool: Arizona Health Care Cost Containment

System

Location: DocuSign

Signer Events Signature Timestamp Akshay Bhandari

ABhandari@sandata.com

CFO

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

Using IP Address: 174.206.236.168

Signed using mobile

Sent: 9/29/2023 3:35:32 PM

Viewed: 9/29/2023 3:45:02 PM

Signed: 9/29/2023 3:45:11 PM

Electronic Record and Signature Disclosure:

Accepted: 9/29/2023 3:45:02 PM ID: 410d5035-83db-4c76-98dd-6958c3a98fa1 Company Name: Carahsoft OBO Arizona Health Care Cost Containment System

Tracey Thomas

Tracey.Thomas@azahcccs.gov

Procurement Manager

Arizona Health Care Cost Containment System

(AHCCCS)

Security Level: Email, Account Authentication (None)

Signature Adoption: Pre-selected Style

Using IP Address: 20.245.184.185

Sent: 9/29/2023 3:45:12 PM

Viewed: 9/29/2023 3:45:50 PM

Signed: 9/29/2023 3:45:53 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 Angel Newsom

ANewsom@sandata.com

Security Level: Email, Account Authentication (None)

Sent: 9/29/2023 3:45:54 PM

Electronic Record and Signature Disclosure:

Carbon Copy Events Status Timestamp Not Offered via DocuSign

Morgan Eisenstein

MEisenstein@sandata.com

Security Level: Email, Account Authentication (None)

Sent: 9/29/2023 3:45:55 PM

Electronic Record and Signature Disclosure:

Not Offered via DocuSign

Katie Morris katie.morris@azahcccs.gov

Security Level: Email, Account Authentication (None)

Sent: 9/29/2023 3:45:56 PM

Electronic Record and Signature Disclosure:

Not Offered via DocuSign

Marna Richmond marna.richmond@azahcccs.gov

Application Development Manager

Security Level: Email, Account Authentication (None)

Sent: 9/29/2023 3:45:56 PM

Electronic Record and Signature Disclosure:

Accepted: 3/16/2023 5:20:45 PM ID: 335ef109-a912-4ca4-8bd4-491b38402c46 Company Name: Carahsoft OBO Arizona Health Care Cost Containment System

Dara Johnson dara.johnson@azahcccs.gov

Program Development Officer

Security Level: Email, Account Authentication (None)

Sent: 9/29/2023 3:45:57 PM

Electronic Record and Signature Disclosure:

Accepted: 5/30/2023 10:38:00 AM ID: da44c0b2-9dc4-4ecd-b5e7-d88072849d3e Company Name: Carahsoft OBO Arizona Health Care Cost Containment System

Michelle Mushrush michelle.mushrush@azahcccs.gov

Security Level: Email, Account Authentication (None)

Sent: 9/29/2023 3:45:57 PM

Electronic Record and Signature Disclosure:

Not Offered via DocuSign

Budget

BUDGET@azahcccs.gov

Security Level: Email, Account Authentication (None)

Sent: 9/29/2023 3:45:58 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 9/29/2023 3:35:32 PM

Certified Delivered Security Checked 9/29/2023 3:45:50 PM

Signing Complete Security Checked 9/29/2023 3:45:53 PM

Completed Security Checked 9/29/2023 3:45:58 PM

Payment Events Status Timestamps

Electronic Record and Signature Disclosure

ELECTRONIC RECORD AND SIGNATURE DISCLOSURE

From time to time, Arizona Health Care Cost Containment System (we, us or Company) may be required by law to provide to you certain written notices or disclosures. Described below are the terms and conditions for providing to you such notices and disclosures electronically through the

DocuSign system. Please read the information below carefully and thoroughly, and if you can access this information electronically to your satisfaction and agree to this Electronic Record and

Signature Disclosure (ERSD), please confirm your agreement by selecting the check-box next to

‘I agree to use electronic records and signatures’ before clicking ‘CONTINUE’ within the

DocuSign system.

Getting paper copies

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

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

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

Withdrawing your consent

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

Consequences of changing your mind

If you elect to receive required notices and disclosures only in paper format, it will slow the speed at which we can complete certain steps in transactions with you and delivering services to you because we will need first to send the required notices or disclosures to you in paper format, and then wait until we receive back from you your acknowledgment of your receipt of such paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to receive required notices and consents electronically from us or to sign electronically documents from us.

All notices and disclosures will be sent to you electronically

Electronic Record and Signature Disclosure created on: 2/9/2023 8:44:33 AM Parties agreed to: Akshay Bhandari, Marna Richmond, Dara Johnson

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

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

How to contact Arizona Health Care Cost Containment System:

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

To contact us by email send messages to: anthony.flot@azahcccs.gov

To advise Arizona Health Care Cost Containment System of your new email address

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

If you created a DocuSign account, you may update it with your new email address through your account preferences.

To request paper copies from Arizona Health Care Cost Containment System

To request delivery from us of paper copies of the notices and disclosures previously provided by us to you electronically, you must send us an email to anthony.flot@azahcccs.gov and in the body of such request you must state your email address, full name, mailing address, and telephone number. We will bill you for any fees at that time, if any.

To withdraw your consent with Arizona Health Care Cost Containment System

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

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

ii. send us an email to anthony.flot@azahcccs.gov and in the body of such request you must state your email, full name, mailing address, and telephone number. We do not need any other information from you to withdraw consent.. The consequences of your withdrawing consent for online documents will be that transactions may take a longer time to process..

Required hardware and software

The minimum system requirements for using the DocuSign system may change over time. The current system requirements are found here: https://support.docusign.com/guides/signer-guide-signing-system-requirements.

Acknowledging your access and consent to receive and sign documents electronically

To confirm to us that you can access this information electronically, which will be similar to other electronic notices and disclosures that we will provide to you, please confirm that you have read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for your future reference and access; or (ii) that you are able to email this ERSD to an email address where you will be able to print on paper or save it for your future reference and access. Further, if you consent to receiving notices and disclosures exclusively in electronic format as described herein, then select the check-box next to ‘I agree to use electronic records and signatures’ before clicking ‘CONTINUE’ within the DocuSign system.

By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm that:

You can access and read this Electronic Record and Signature Disclosure; and

You can print on paper this Electronic Record and Signature Disclosure, or save or send this Electronic Record and Disclosure to a location where you can print it, for future reference and access; and

Until or unless you notify Arizona Health Care Cost Containment System as described above, you consent to receive exclusively through electronic means all notices, disclosures, authorizations, acknowledgements, and other documents that are required to be provided or made available to you by Arizona Health Care Cost Containment System during the course of your relationship with Arizona Health Care Cost Containment

System.

https://support.docusign.com/guides/signer-guide-signing-system-requirements https://support.docusign.com/guides/signer-guide-signing-system-requirements