Backup Documents 04/08/2025 Item #16D 2 ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP 1 6 D 2
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO 4.8.24 BCC MTG
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Carolyn Noble Community and Human CN 3.10.25
Services
2. County Attorney Office— County Attorney Office
AAk/M1 y/g f zs
3. BCC Office Board of County
Commissioners isg)N Y l$(ZS . ��4. Minutes and Records Clerk of Court's Office a
VAS
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the addressees
above,may need to contact staff for additional or missing information.
Name of Primary Staff Carolyn Noble Phone Number 239-450-5186
Contact/ Department
Agenda Date Item was 4.8.25 BCC Mtg Agenda Item Number 16.D.
Approved by the BCC
Type of Document 3 CHSI STATE MANDATED/LIP MOU'S Number of Original 3 DOCUMENTS
Attached Documents Attached
PO number or account
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A"in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature STAMP OK CN
2. Does the document need to be sent to another agency for additional signatures? If yes, N/A
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be Yes
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's N/A
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the N/A
document or the final negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's YES
signature and initials are required. _
7. In most cases(some contracts are an exception),the original document and this routing slip N/A
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on above date and all changes made during N/A is not
the meeting have been incorporated in the attached document. The County /A4hti an option for
Attorney's Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the N/A is not
BCC,all changes directed by the BCC have been made,and the document is ready for the 0,6 an option for
Chairman's signature. S this line.
1 6 D ' 2
MEMORANDUM
Date: April 9, 2025
To: Carolyn Noble, Grants
Community & Human Services
From: Martha Vergara, Sr. Deputy Clerk
Minutes & Records Department
Re: Collier Health Services, Inc., d/b/a HealthCare Newwork of Southwest
Florida
MOU
Enclosed please find two (2) originals of each document referenced above (Agenda
Item #16D2), approved by the Board of County Commissioners on Tuesday, April 8,
2025.
The Minutes & Records Department has retained an original as part of the Board's
Official Records.
If you have any questions, please contact me at 252-7240.
Thank you.
Enclosure
16D 2
MEMORANDUM OF UNDERSTANDING BETWEEN COLLIER COUNTY
AND
COLLIER HEALTH SERVICES, INC.,d/b/a HEALTHCARE NETWORK OF SOUTHWEST
FLORIDA
THIS MEMORANDUM OF UNDERSTANDING (MOU) is made and entered into on
this 84A day of Aer;1 2025 by and between Collier County, a political subdivision of
the State of Florida(COUNTY), having its principal address as 3339 E.Tamiami Trail,Naples,FL
34112, and Collier Health Services, Inc., d/b/a Healthcare Network of Southwest Florida
(RECIPIENT) a Florida not-for-profit corporation having its principal address at 1454 Madison
Ave West, Immokalee, FL 34142 .
WHEREAS, Section 125.01(1)(e), Florida Statutes, authorizes the COUNTY to provide
health welfare programs for the residents of Collier County to the extent not inconsistent with
general or special law; and
WHEREAS, the establishment and maintenance of such programs are in the common
interest of the people of Collier County; and
WHEREAS,The COUNTY desires the RECIPIENT to become a community health partner
to assist in providing services for uninsured and underinsured Collier County residents with medical
and health prevention services; and
NOW THEREFORE,in consideration ol'the mutual benefits contained herein, it is agreed
by the Parties as follows:
PART I
SCOPE OF SERVICES
1.1. The RECIPIENT shall in a satisfactory and proper manner and consistent with any standards
required as a condition of providing services as provided herein and as determined by Collier
County Community and Human Services (CHS) Division, perform the tasks necessary to
provide:
A. Provide Women's health services for pregnant and postpartum women
B. Provide medical payments to providers as approved by Collier County.
C. Provide health prevention services to eligible residents of Collier County.
D. Provide medical services to the uninsured and underinsured residents of Collier
County
Collier Health Services
MOU-State Mandated/Low Income Pool 24-25 CAD
16D 2
1.2. The RECIPIENT and/or its approved subcontractor shall provide timely responses to all
requirements.
1.3 Performance Deliverables
A. Clients Served
The RECIPIENT will serve the following:
i. Women's Health: deliver services to a minimum of'132 non-duplicated pregnant
and/or post-partum women (Collier County residents) with at least one (1) unit of
service. Clients may receive duplicated services; only one unit of service will be
applied to minimum number of clients served.
ii. Medical payments: the RECEPIENT will pay all invoices for referred treatment
received by the COUNTY in a timely manner.
iii. Health prevention and medical services: a minimum of 500 non-duplicated
underinsured/uninsured Collier County residents with at least one(1)unit of service.
Clients may receive duplicated services; only one unit of service will be applied to
minimum number of clients served.
B. Performance Deliverables
Program Deliverable Supporting Documentation Submission Schedule
Insurance Proof of coverage in Within 30 days following
accordance with Exhibit B MOU execution and
annually thereafter
Quarterly Performance Exhibit C Quarterly by 30th of the
Report month following quarter end
Accreditation Agencies Final Audit/Monitoring Within 30 days of receipt
and/or Audit Reports Reports including any plans
of corrective action
Single Audit Audit report and Within 9 months of end of
management letter fiscal year
2
Collier Health Services
MOU-State Mandated/Low Income Pool 24-25
CAO
16D 2
PART II
PAYMENTS
The COUNTY shall make intergovernmental transfers on behalf of the RECIPIENT, in connection
with the Low Income Pool (LIP) program, to the State of Florida (State) in accordance with the
Letter of Agreement between the COUNTY and the Agency for Health Care Administration
(AHCA).
2.1. The COUNTY will remit to AHCA an amount not to exceed '$543,345.00.. The COUNTY
will transfer payment to the AHCA in the following manner:
A. The payments for the months July 2024 — June 2025 ; are subject CMS approval of the
LIP reimbursement and funding methodology document. Once approved, IGT invoices
will be sent out. When payments are received, one payment will be made to Collier
Health Services, Inc. by AHCA. This timeframe has not yet been determined.
B. The COUNTY is providing a local match amount of$543,345.00 for eligible services.
2.2 The following document is hereby incorporated by reference as Exhibit A to this MOU: Low
Income Pool Agreement(LIP)with the State of Florida Agency for Healthcare Administration
(AHCA) reflecting the anticipated annual distributions for State Fiscal Year 2024-2025
PART III
TERMS OF MOU AND TERMINATION
3.1. The term of this MOU shall be October 1. 2024. through September 30, 2025 with no
renewal.
3.2. Either party may terminate this MOU thirty (30) calendar days after receipt of written notice
of intent to terminate from the other party and should the RECIPIENT choose to terminate
the RECIPIENT is obligated to return the pro-rated share of the COUNTY'S funds paid on
the RECIPIENT'S behalf to AHCA.
3.3. Upon breach of this MOU, the aggrieved party may, by written notice of breach to the
breaching party. terminate the whole or any part of this MOU. Termination shall be upon no
less than 24 hours notice,in writing,delivered by certified mail,or in person. Waiver by either
party of breach of any provisions of this MOU shall not be deemed to be a waiver of any other
or subsequent breach and shall not be construed to be a modification of the terms of this
MOU.
Collier Health Services
MOU-State Mandated/Low Income Pool 24-25
C?.O
16D ' 2
3.4 It is further agreed that in the event general funds to finance all or part of the AHCA LIP
agreement do not become available, the obligations of each party hereunder may be
terminated upon no less than 24 hours notice in writing to the other party. Said notice shall
be delivered by certified mail, or in person.
3.5 It is further agreed that the RECEIPIENT shall set aside $250,000 for the benefit of County
supported health programs. The County shall refer uninsured person to medical providers for
services and all invoices shall be paid by the RECIPIENT within 60 days of receipt and at
the Medicaid rate. The Collier County Community and Human Services Medical program is
funded with$100,000 and the Women's Health program$150,000. At anytime CHS reserves
the right to reallocate funds from the CHS medical program to the Women's Health program.
PART IV
NOTICES
Notices required by this MOU shall be in writing and delivered via mail (postage prepaid),
commercial courier, personal delivery, or sent by facsimile or other electronic means. Either
party may change the address to which notices are to be sent to it by giving written notice of
such change to the other party in the manner herein provided for giving notice. Any notice,
request, instruction, or other document delivered or sent as aforesaid shall be effective on the
date of delivery or sending. All notices and other written communications under this MOU shall
be addressed to the individuals in the capacities indicated below, unless otherwise modified by
subsequent written notice.
COLLIER COUNTY ATTENTION:'Carolyn Noble, Grant Coordinator
Collier County Government
Community and Human Services Division
2671 Airport Pulling Road, Suite 202
Naples, Florida 34112
Email: carolyn.noble@colliercountyfl.gov
Telephone:(239) 450-5186
RECIPIENT ATTENTION: Tami Raznof£ CFO
Collier Health Services
1454 Madison Ave West
Immokalee, FL 34142
Email: traznoff@healthcareSWFL.org'
Telephone: (239)658-3137
4
Collier Health Services
MOU-State Mandated/Low Income Pool 24-25 f C.4
16D 2
PART V
ASSIGNMENT
The RECIPIENT and/or its subcontractors shall not assign or transfer this MOU, or any interest,
right, or duty herein, without the prior written consent of the COUNTY.
PART VI
SUBCONTRACTING
The parties agree that, upon approval of the COUNTY, the RECIPIENT shall be permitted to
execute subcontracts for the purchase of such services, articles, supplies, and equipment that are
both necessary and incidental to the performance of the work required under this MOU. However,
the RECIPIENT expressly understands that it shall assume the primary responsibility for
performing the services outlined in Part I of this MOU.
PART VII
INSURANCE, SAFETY, AND INDEMNIFICATION
7.1. Indemnity: To the maximum extent permitted by Florida law, the RECIPIENT and/or its
subcontractors shall indemnify and hold harmless the COUNTY against any claims,
damages, losses, and expenses, including reasonable attorney's fees and costs,arising out of
or resulting from the RECIPIENT'S failure to pay for services or performance under this
MOU. This indemnification obligation shall not be construed to negate, abridge, or reduce
any other rights or remedies which otherwise may be available to an indemnified party or
person described in this paragraph.
The RECIPIENT shall jointly and severally indemnify and hold harmless the COUNTY for
all claims demands, actions, suits, losses, costs, charges, expenses, damages, and liabilities
whatsoever which the COUNTY may pay, sustain, suffer, or incur by reason of or in
connection with this MOU, including payment of all legal costs, including but not limited to
attorney's fees paid by the COUNTY.
7.2. Insurance Required: The RECIPIENT shall not commence any work and/or services
pursuant to this MOU,until all required insurance,as outlined in Exhibit B has been obtained.
Said insurance shall be carried continuously during the RECIPIENT's performance under
this MOU.
5
Collier Health Services
MOU-State Mandated/Low Income Pool 24-25
16D 2
PART VIII
RECORDS
The RECIPIENT and/or its subcontractors shall keep orderly and complete records of its accounts
and operations related to the services provided under this MOU for the entire term of the MOU plus
six(6)years. The RECIPIENT and/or its subcontractors shall keep these records open to inspection
by COUNTY personnel at reasonable hours during the entire term of this MOU. If any litigation,
claim, or audit is commenced prior to the expiration of the six (6) year period and extends beyond
this period, the records must remain available until any litigation, claim, or audit has been resolved.
Any person duly authorized by the COUNTY shall have full access to, and the right to examine any
of said records during said period. Access to Protected Health Information (PHI) shall comply with
federal laws and the Health Insurance Portability and Accountability Act (HIPAA).
PART IX
CIVIL RIGHTS
9.1. In the performance of this MOU, there will be no discrimination against any employee or
person served based on race, color, sex, age, religion, ancestry, national origin, handicap, or
marital status.
9.2. It is expressly understood that, upon receipt of evidence of such discrimination, the
COUNTY shall have the right to terminate this MOU for breach of MOU.
9.3. The RECIPIENT and/or its subcontractors shall comply with Title VI of the Civil Rights
Act of 1964 (42 USC 2000(d)) regarding persons served.
9.4. The RECIPIENT and/or its subcontractors shall comply with Title VII of the Civil Rights
Act of 1964 (42 USC 2000(c)) regarding employees or applicants for employment.
9.5. The RECIPIENT and/or its subcontractors shall comply with Section 504 of the
Rehabilitation Act of 1973 regarding employees or applicants for employment and clients
served.
PART X
OTHER CONDITIONS
10.1. The COUNTY or the RECIPIENT may amend this MOU at any time, provided that such
amendments make specific reference to this MOU, are executed in writing, signed by a duly
authorized representative of each organization, and approved by the COUNTY'S Board.
6
Collier Health Services
MOU-State Mandated/Low Income Pool 24-25
(
16D ' 2
Such amendments shall not invalidate this MOU, nor relieve or release the COUNTY or the
RECIPIENT from its obligations under this MOU.
The COUNTY may, in its discretion, amend this MOU to conform with Federal, State. or
Local governmental guidelines, policies, available funding amounts, or other reasons. If
such amendments result in a change in the funding, scope of services, or schedule of the
activities to be undertaken as part of this MOU,such modifications will be incorporated only
by written amendment, signed by both COUNTY and the RECIPIENT.
10.2. This MOU contains all the terms and conditions agreed upon by the parties. All items
incorporated by reference are as though physically attached. No other agreements. oral or
otherwise,regarding the subject matter of this MOU, shall be deemed to exist or to bind any
of the parties hereto.
10.3. The RECIPIENT and/or its subcontractors shall obtain and possess throughout the term of
this MOU all licenses and permits applicable to its operations under federal, state, and local
laws, and shall comply with all fire, health, and other applicable regulatory codes.
10.4. The RECIPIENT and/or its subcontractors agree to comply with all applicable requirements
and guidelines prescribed by the COUNTY for recipients of funds.
10.5. The RECIPIENT and/or its subcontractors shall comply with all applicable state and federal
laws including Health Insurance Portability and agree to safeguard the privacy of
information pursuant to HIPAA regulations.
10.6. If the RECIPIENT provides services to clients under this MOU, the RECIPENT and any
subcontractors shall report knowledge or reasonable suspicion of abuse, neglect, or
exploitation of a child, aged person, or disabled person to the COUNTY. During the term
of this MOU,the RECIPIENT must report to the COUNTY in writing, within one business
day of occurrence, any substantial, controversial, or newsworthy incidents. The Collier
County Standard Incident Report Form shall be used to report all such incidents(Exhibit D,
attached).
Signature Page to Follow
7
Collier Health Services
MOU-State Mandated/Low Income Pool 24-25
(co
16D . 2
IN WITNESS WHEREOF, the RECIPIENT and COUNTY have each respectively, by an authorized
person or agent, hereunder set their hands and seals on the date first written above.
ATTEST: AS TO COUNTY:
CRYSTAL K. KINZEL, CLERK
BOARD OF COUNTY COMMISSIONERS OF
COLLIER COUNTY, FLORIDA
1' f
est as to ChaT4tan'• ut Clerk
siarature Orfj- By CY•�I +--
rt B R L. SAU ERS, CHAIRPERSON
Dated ate0-0(-35
(SEAL) Date: 4/$/2.5
AS TO RECIPIENT:
WITNESSES:
COLLIER HEALTH SERVICES, INC.•
Witness#1 Signatur By:
TAMI RA N FE, F
,44 f� -
Witness #1 PrintedNa.ie Date: 3/ 9 f 20 a'S
INC'i _1W U.' to t [Please provide evidence of signing authority]
Witness#2 Signature
__- .,64)4•Witness #2 Printed ame
App . -III s_to • and legality:
�
_a.i1L.
lit
Jeff Al
' 11 zkow
Coun . Ai rney
Date: iJiq r
8
Collier Health Services
MOU-State Mandated/Low Income Pool 24-25 �)
.0
16D 2
EXHIBIT A
LOW INCOME POOL AGREEMENT
16D 2
Low Income Pooi Letter of Aureentent
f;:,
THIS LETTER OF AGREEMENT(LOA;is rr,aie and entered:rto it tit:pi:cute en he �`t__
day crook ,.; _2C24, by and bntween Collor County 13oCC(the'It;7 Provider")on behalf
at Noaithc-atte Network of Southwest Ficrida and the State o`Florida_Agency for Health
Care Administration(Soo'Agoncy for good arid Valuable Cors'de-ato't,the(ocelot and
sufficiency of which is acknawk figcti.
DEFINITIONS
*Charly tiro"to*ancomvensate;t charity care'reaps 7r1a1 Coriior c!hospitaw charges reported
to die Agency for which there is ro compertsal:or,MOT than restricted or unrestricted revenues
p twitted to a hospital by local ctovernnlei is or tax districts refardinss of the method of payment.
Uncompensated care includes chu'ity core`or trio wills..dui hot noes nc!lorOudc
uncompensated care for iosured rd•v,dua's,bad debt,or Medicaid aoc Ch toren.>I+ealth
Insurance i'ro ram(CHIP)shortfall. the state and providers that are prtrt.ctnat:ng rr:Low
Income Pool(UP)w.t provide assuranco that L+P ctrtirtts Include only coats nesecwtod v,J"r
urcu•nponsateed care that N furnished through a charity care program..and Thal adheres to the
pr.nciplco of the Hea,therre Financial Mnrragertent A4socratlon(rif i/A)operated ty the
provider
Intrrgovernrr.ertal Transfers('G I's)"moans transfers of funds from a nee-Medica.e
governmental eriity lo.g.,emetics,l'osrltai tnxtng districts,providers operated by stele cr local
gnvernrrant)to the Medicaid agency IG''s must be coripliont with 42 CFR Part 433 Subpart U.
'low!Kerrie Pool(LI-' moans providing government support for:safety-net ornv4eM for the
costs of encompensated charity cure for tow income individuals who are uninsured.
Urtcz.:rnpensated care Inctr:des charity onto for too uninsured but dons net Include
u^Contpercated ewe fur Intoned frdividrrafs,'cad cent,'or Medicaid and CHIP shortie!;
"Medicare rnrr.ar s the reed cat a*ltstance c rora:arr author Teri by Ice XlX of trio Spoiat Security
Act,42 U.S.C.§§ 139f3 et see.,and reg.rfat•o:s th4rrovndnr ar.wire ioiste4ud in tlonde by the
Agency
A. OI:NLRAL PROVISIONS
1. Per Ho..sc 13':5001,the General Appropriations Act of State Fiscal Year 2024-2025.
passed by the 2024 Florida Legtsfaturor the 1GT Provider and the Agoncy agree that the
GT Prov!Cer will remit IGT funds to the AgencyIn en amount not to lucent('the total of
$643,346.00 tf the entire State Fiscal Yon,(Sr lucent('v)24 25 dtstr>rrtirnrr:s paid rrainr the
enhanr..00 I-et:erra!Meoica'Assinta^,ce^ercentage(r t/AP)per the Forniins f•rot
Coronae sus Response AG or it a portion of the,,f Y24-25 d:siribrtron:c paid after the
expiation of the end of the enhanced FMAP.
a 'fee IG T Provider and the Agency have agreed that these IGT funds w,il only are
used to rrtti'eese lie provision of health services for the charity pats of the IG—
P'o+-der arid the State of Florida at large.
v, —he increased provison of chanty care hoatth services be accornplisieJ
through ten fol.awfog Meorca d programs.
UP payments to hoxpita s,lodoraCy oualifiod ovate.,caters,Medrear
School Physician Practices.commntty be'+aviora,nraflh providers. and
rgx,►r
fared av t nr;
Cole C_trrry SoCC qvceicstfa Notvn'K cr SvU 11wa94r t'l3rrru_t to,.^.1 RF+'2024Ln] I:ytt
r4;p5 iX
C 4.0)
16D . 2
(ura health centers pursuant to the aporcved Centers fit Med.ca«,h
Medicaid Services Scecial Terms and Cord Lions
'Inc,1GT Prov,rler y.iit return the;:fined LOA to the Agency no rater than October 1,2024
1 The if;T Provider wit'pay Kit: !ands to Ito Agency in an amount ref to exceed tt:H Iola!of
$643,346.00 it the.entire$I Y24.25 dr3irttt tor. s paid peor'a the e'4 of the arrtrtic neeIt.
emergency of Ito portion of the SFY24 25 distribution is paio atter the err o'the oolitic
hoa'th ornetgeruy.
a. iaer Flnridr Sta:uto 409.909,annual payments for The months of July 2024 through
Jure 202fii are due to the f%Tanry no tater lean October 31.2024,uriess at:
a'lernalvc plan is specifically approved ay the agency
h The Agency will bit the iG'Provider when payrnent is due.
3 The 1U7 Previcet'and the Agency agree Utz:the Agoney w t maintain ru>•cessary records
and supporting c oarrreriatir r uppl table to health surv:cas coveted by this LOA
a. Aunts and Records
i The!G T Provides agrees to rna-nta n banks,records,and deQ14143111s
(lnciuding electronic storage rnecia)pert_nnnt to pertormar.tc,s.nder fn's 1.
0 A in accorcance with generally accepted acco.irtin0 procedures aid
cracl'cos.which sufficiently and property ref.ect nil revenues anti
expenditures of funds provided.
'the IS;Provider agrees to asstro teat these records shalt be sJt)oct et all
reasonable lures to inspection.review rr:nud:t by state porsunne and
other pprt.crnct duty authorized by the Alacnc;y as well ,s by federal
personna:.
ii, Thu 1G i Provider agrees to comply.v its p.'Cii::-ecort taws as ottl nod in
section 119.0701,Faarida Statutes.
o. Retention of Records
Tee 1ST Provider agrees to rcttr•n a'(i••.an.:fat race-as.supporting
docurnonta.statis1tcnl records.and any other documents fint.A4firfi
i
otct:tronic stodge media))pertinent to perfcr-lance under(tits LOA!pi
period of six(b)years after tenrinet.rn of th's 1 0A,or if an audit has bean
initialed and audit lied nos have not born resolved et the end of six(ri)
years,U e records shall be retained until res:lotion n'the audit findings
ii. Persons duty authorised-y the Agency and Larder&auditors shall hive fuf
access tc and the right to examine ary of sae.,records arid doewnurls.
Ccs1+ r Ctr ty 1 CC_Heakxs^c rartav[k:f svia:weir r'a.7ria LP LOA DPI'20:4,ts
(CAO
16D 2
1. The rights of access in th s section rn'sc rot hi ltnlrnn hi tie required
rotenban period out sh i!ast as tong as the records ere retained
c Monrtorirq
:he IG r i•'rovidcr agrees to permit ;,;'sons (holy authorized by tin'
Agency to Inspect env recrcis papas,and documents of the IGT
provider which are relevant lc tins LOA.
c Assiu+rr•-urt an,i Subcontracts
i '!re IGT Ptvv:d'ir 2grecs In neither assign tree respons tiny n't"is LOA
to arcr{ner potty nor succantract for any o'th0 work canterrrraten tinder
lh s LOA without pro written app.uvat of the Agency. No such approval
by the Agency cf any assignment o:subcontract shot be c ocrrou!r Any
overt Cr In any manner to provide lot !ere ir.cr:rranc,u of any obligation of
din Agency:r ad itior to the tote Callan atus.nit agreed uoor in ill's
t.OA An such assignrrtants cr subccntr,rrls'hail be suhit±ct tri the
a:10i601m o'this LOA and to any corxi.to'rs of allure-a that the Agency
shel duce necessary
This LOA may ony be amended upon written agreement sig^.ed by both parries.
Thy'GT Provider and the Agency arree Mat any mcdrficot suns to this LOA strati be in
the swine fern(,namely the exchange of signed conies of a revrse•7 WA.
5 the IG I Provider confirms that there are no tirc•arraricred agreement*(c onlraCtua!or
0lrianvtao)between the respective counties,taxing ais!ricts,areift rho provirrois In rr.-
rfreci arty Nation of these aforementioned charity CAT s,rpptonrr,tel payments n order
to satisfy non-Medicaid,non-t:ninsured.and ron-tinderxtsrvr<d activ tees.
f3 The 1C;I ProviJer agrees the following provisia n shah be included in ary agrcc.^xmic
be?wrien the IG r Provider non local providers whirr, IOT funding ts provided p.,rsuant
to this t OA.'Funding Ixcvicfed in this Agreerr.ent that he Or'orltized so that designated
IG7 turd ng shall fast he used to fund the t,!eoicaai program(indicting LIP or OS!I)uvtd
sis td secondarily for ether purposes.'
7. this WA covers the period at July t,7024 through Junn 3C,2705.nod shirt
oe tern►'natet September;tt;,202H.which Induces the states codified forward
period
A. This LOA may be executed in multiple counterparts,each of;phis('sea'i constitute an
original,and each of which shots Pe'Ally t:ruling on tiny party signing at least runt
counterpart
Cu•ler C Arty esce.ties-axatc tvetwayb nt e:+e3 I Ile Lc lit SF :024 2S
1 6D 2
.LIP-Local Intergovernmental Transfers (1GTs)
Program I Amount State Fiscal Year 2024-2025
Estimated IGTs
$543,3,15,00
Total Funding Not to Exceed
$543,345.00
WITNESSETH:
IN WITNESS WHEREOF,the parties?save caused this(4)page Letter of Agreemen'
to be executed by their unde•signed cff.ciais as duly authorized
COLLIER COUNTY BOCC STATE OF FLORIDA,AGENCY FOR
HEALTH CARE ADMINISTRATION
SIGNED ! � SIGNED
NAME: Amy Patterson .�NAME'..
SlaGi Griffis. ..,_. .__..
TITLE: County Manager TITLE: Act rg Civet-Medicaid Program
Finance
n c,/
DATE: ._? _a5 !' ! DATE: «VL Z• \-1,01,• �_ __ ....
7 w
Appro d a z0.tem)and legality
Jeffrey(.l'llatzitow,County Attorney
cover Coulty 13OCC_tv&UPcage Ne w;xk o Sc 'i v !Florid*,L'P LOA SLY 2024-2S
EXHIBIT B
C�H�
I 6 D 2
INSURANCE REQUIREMENTS
The CONTRACTOR shall furnish to Collier County, c/o Community and Human Services
Division, 3339 Tamiami Trail East, Suite 213, Naples, Florida 34112, Certificate(s) of Insurance
evidencing insurance coverage that meets the requirements as outlined below:
1. Workers' Compensation as required by Chapter 440, Florida Statutes.
2. Commercial General Liability, including products and completed operations insurance,
in the amount of$1,000,000 per occurrence and $2,000.000 aggregate. Collier County
must be shown as an additional insured with respect to this coverage.
3. Automobile Liability Insurance covering all owned, non-owned and hired vehicles used
in connection with this MOU, in an amount not less than $1,000,000 combined single
limit for combined Bodily Injury and Property Damage.
DESIGN STAGE (IF APPLICABLE)
In addition to the insurance required in 1 — 3 above, a Certificate of Insurance must he provided as
follows:
4. Professional Liability Insurance, in the name of the CONTRACTOR or the licensed
design professional employed by the CONTRACTOR, in an amount not less than
$1,000,000 per occurrence/$1,000,000 aggregate providing for all sums which the
CONTRACTOR and/or the design professional shall become legally obligated to pay as
damages for claims arising out of the services performed by the CONTRACTOR or any
person employed by the CONTRACTOR in connection with this MOU. This insurance
shall be maintained for a period of two (2) years after the Certificate of Occupancy is
issued.
CONSTRUCTION PHASE (IF APPLICABLE)
In addition to the insurance required in 1 —4 above, the CONTRACTOR shall provide, or cause its
Subcontractors to provide, original certificates indicating the following types of insurance coverage
prior to any construction:
5. Completed Value Builder's Risk Insurance on an"All Risk" basis, in an amount not less
than 100 percent of the insurable value of the building(s)or structure(s). The policy shall
be in the name of Collier County and the CONTRACTOR.
6. In accordance with the requirements of the Flood Disaster Protection Act of 1973 (42
U.S.C. 4001), the CONTRACTOR shall assure that for activities located in an area
identified by the Federal Emergency Management Agency (FEMA) as having special
flood hazards, flood insurance under the National Flood Insurance Program is obtained
and maintained, as a condition of financial assistance for acquisition or construction
purposes (including rehabilitation).
•
(cMi
16D ' 2
OPERATION/MANAGEMENT PHASE (IF APPLICABLE)
After the Construction Phase is completed and occupancy begins, the following insurance must he
kept in force throughout the duration of the loan and/or MOU:
7. Workers' Compensation as required by Chapter 440, Florida Statutes.
8. Commercial General Liability including products and completed operations insurance
in the amount of$1,000,000 per occurrence and $2,000,000 aggregate. Collier County
must be shown as an additional insured with respect to this coverage.
9. Automobile Liability Insurance covering all owned, non-owned and hired vehicles used
in connection with this MOU in an amount not less than $1,000,000 combined single
limit for combined Bodily Injury and Property Damage.
10. Property Insurance coverage on an "All Risk" basis, in an amount not less than 100
percent of the replacement cost of the property. Collier County must be shown as a Loss
payee, with respect to this coverage A.T.I.M.A.
11. Flood Insurance coverage for those properties found to be within a flood hazard zone,
for the full replacement values of the structure(s) or the maximum amount of coverage
available through the National Flood Insurance Program (NFIP). The policy must show
Collier County as a Loss Payee A.T.I.M.A.
��O
16D 2
EXHIBIT C
PROGRESS REPORT
Subtecipient Name: ; Collier Health Services
Report Period:
Fiscal Year: 2024-2025
Program: State Mandated/LIP
Contact Name: Tami Raznoff
-- -------_.__---------
Contact Number:
1st 2nd 3rd 4th Cumulative Target
Quarter
Performance Measures Quarter Quarter Quarter 7/1 To Number to
Women's Health Services 10/1- 1/1-3/31 4/1-6/30 Date be served
12/31 9/30 Annually
Number of Individual
Served (unduplicated) 132
Number of Service Units
4th
1st 2nd 3rd Quarter Cumulative
Medical Program Quarter Quarter Quarter 7/1- To
10/1 1/1-3/31 4/1-6/30 9/30 Date
12/31
Number of CHS Referred
Clients
Number of Services
Authorized
ClIS Expenditure Amount
Incurred
Expenditures Paid to Date
16D 2 11
4th
1st 2nd 3rd Quarter Cumulative Target
Health Prevention and Quarter Quarter To Number to
Medical Services Q oiler 1/1-3/31 4/1-6/30 9/30 Date be served
12/31 Annually
Number of Clients Served 500
Number of Service Units
Signature Date
Title
16D 2
EXHIBIT D
INCIDENT REPORT FORM
Organization Name:
Organization Address:
Project No:
Grant Coordinator:
Date of Incident Time of Incident:
Report Submitted By:
(Name&Phone) _
Description of Incident:
Location/Address of Incident:
Was Police Report Filed? ❑ Yes ❑ No
If Yes, Police Report Number: Jurisdiction:
Were there any warning signs that this type of Incident could occur? ❑ Yes ❑ No
If Yes, Explain:
What actions will be taken to prevent a recurrence of a similar incident?
i I
I certify under penalty of perjury under F.S. 837.06 that the contents of this affidavit are true and correct.
Signature of Person Making Report Date
Printed Name
Title