HomeMy WebLinkAboutResolution - 2023-R0439 - HHSC Contract No. HHS000779500006, COPSD - 09/12/2023Resolution No. 2023-R0439
Item No. 5.34
September 12, 2023
RESOLUTION
BE IT IZESOLVED BY THE CITY COUNCIL OF TI IE CITY OF LUBBOCK:
TI IAT the acts of the Mayor of thc City of Lubbock in executing, on behalf of the City of
Lubbock, Amendment No. 2 to the Health and IIuman Services Commission Contract No.
HHS000779500006, under the Co-occun•ing Psychiatric and Substance Use Disorders (COPSD)
Grant Program, by and between the City of Lubbock and the State of Texas' IIealth and Human
Services Commission, and all related documents are hereby ratificd in full. Said Amendment is
attached hereto and incorporated in this resolution as if fully set forth herein and shall be
included in the minutes of the City Council.
Passed by the City Council on _ September 12, 2023
APPROV�D AS TO CONT�N1':
Bill I erton, Deputy '' y anager
�77Z�lif � : �C�fO��T�ir�
Rachael roster, As is�{�ant City Attorney
RGS.HI�SC Contract No. HI-IS000779500006 COPSD Amcndmcnt No.2 Ratification
8.25.23
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
Resolution No. 2023-RO439
HEALTH AND HUMAN SERVICES COMMISSION
CONTRACT No. HHS000779500006
AMENDMENT No. 2
The HEALTH AND HUMAN SERVICES COMMISSION ("HHSC" or "System Agency") and CITY
OF LUBBOCK ("Grantee"), collectively referred to as the "Parties" to that certain Co-occurring
Psychiatric and Substance Use Disorders (COPSD) Contract effective 2/1/2022, and denominated
HHSC Contract No. HHS000779500006 ("Contract'), as amended, now desire to further amend
the Contract.
WHEREAS, HHSC desires to revise Attachment A, Statement of Work, and Attachment B,
Program Services and Unit Rates.
NOW, THEREFORE, the Parties amend and modify the Contract as follows:
1. ATTACHMENT A, REVISED STATEMENT OF WORK is deleted in its entirety and replaced
with ATTACHMENT A, STATEMENT OF WORK (AUGUST 2023).
2. ATTACHMENT B, PROGRAM SERVICES AND UNIT RATES OCTOBER 2022, is deleted in
its entirety and replaced with ATTACHMENT B, PROGRAM SERVICES AND UNIT RATES
(AUGUST 2023).
3. ATTACHMENT H, FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT
(FFATA) FORM is attached to this Amendment and made part of the Contract for all
purposes. Grantee is required to complete the Certification to meet the federal
requirement.
4. The U.S. Health and Services Commission, Substance Abuse and Mental Health Services
Administration (SAMHSA) revised the name of the Substance Abuse Prevention and
Treatment Block Grant (SABG) or (SAPT), assistance listing number 93.959. All
references in the Contract to SABG/SAPT are replaced with the following name:
Substance Use Prevention, Treatment and Recovery Services (SUPTRS) Block Grant.
5. This Amendment No. 2 shall be effective on August 31, 2023.
6. Except as amended and modified by this Amendment No. 2, all terms and conditions of
the Contract, as previously amended, shall remain in full force and effect.
7. Any further revisions to the Contract shall be by written agreement of the Parties.
SIGNATURE PAGE FOLLOWS
HHSC Solicitation No: HHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
Page 1 of 2
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29EO6F
SIGNATURE PAGE FOR AMENDMENT No. 2
HHSC CONTRACT No. HHS000779500006
HEALTH AND HUMAN SERVICES
COMMISSION
DocuSigned by:
B : CFbj ,Yi& SWouA,
y F7QF1QR7A71R4An
Roderick swan
Associate commissioner
CDocuSigned by:
� SWMA,
E79F19B7A7184AD
Date of Signature:
CITY OF LUBBOCK
DocuSigned by:
[firs Pa'IA.�,
B\7. 37610FE32C7148D...
Tray Payne
Mayor
DocuSigned by:
48D
Date of Signature:
The Following Documents are Attached and Incorporated as Part of the Contract:
ATTACHMENT A: STATEMENT OF WORK (AUGUST 2023)
ATTACHMENT B: PROGRAM SERVICES AND UNIT RATES (AUGUST 2023)
ATTACHMENT H: FEDERAL FUNDING ACCOUNTABILITY AND TRANSPARENCY ACT
(FFATA) FORM
HHSC Solicitation No: HHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
Page 2 of 2
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29EO6F
ATTACHMENT A: STATEMENT OF WORK
(AUGUST 2023)
SECTION I: PIJRPOSE
To provide adjunct services to clients with co-occurring psychiatric and substance use disorders
(COPSD), emphasizing integrated services for both mental health needs and substance use
disorders.
TARGET POPULATION
Texas residents who meet Client Eligibility criteria for System Agency -funded services as stated
in the Substance Use Disorder (SUD) Program Guide https://hhs.texas.gov/doing-business-
hhs/provider-portals/behavioral-health-services-providers/substance-use-disorder-service-
providers
SECTION II: SERVICE REQUIREMENTS:
Grantee shall:
A. Administrative Requirements
1. Comply with all applicable Texas Administrative Code (TAC) rules adopted by the
System Agency related to SUD treatment.
2. Document all specified required activities and services in the Clinical Management of
Behavioral Health Services (CMBHS) system. Documents that require client or staff
signature shall be maintained according to TAC requirements and made available to
System Agency for review upon request.
3. Provide age -appropriate medical and psychological therapeutic services designed to
treat an individual's substance use disorder and promote recovery.
4. In addition to TAC and SUD Program Guide required Policies and Procedures,
Grantee shall develop and implement organizational policies and procedures for the
following:
i. A marketing plan to engage local referral sources and provide information to
these sources regarding the availability of substance use disorder treatment,
mental health services, and the Client Eligibility criteria for admissions;
ii. All marketing materials published shall include Priority Populations for
Treatment Programs admissions;
iii. Client Retention in services, including protocols for addressing clients absent
from treatment and policies defining treatment non-compliance; and
iv. All policies and procedures shall be provided to System Agency upon request.
5. Grantee may provide services in Grantee's facility, at the client's home, or other
locations where confidentiality can be maintained.
6. Grantee shall ensure that services are provided in addition to, and not as a replacement
for other services.
7. Grantee's COPSD specialist -to -client ratios shall not exceed 1:20.
8. Grantee shall bill only hours that Grantee's COPSD specialist spends in face-to-face,
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
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one-on-one counseling or case management sessions with a client and shall not bill for
more than three hours per day, per client.
9. Actively attend and share representative knowledge about Grantee's system and
services at the Outreach, Screening, Assessment, and Referrals (OSAR) quarterly
regional collaborative meetings.
10. Ensure compliance with Client Eligibility requirements to include: Texas residence
eligibility, financial eligibility and clinical eligibility as specified in SUD Program
Guide.
11. Grantee will develop a local agreement with Department of Family and Protective
Services (DFPS) local offices to address referral process, coordination of services, and
sharing of information as allowed per the consent and agreement form.
12. Adhere to Memorandum of Understanding requirements as stated in the SUD Program
Guide.
13. In addition, when there are multiple System Agency -funded COPSD Grantees in the
same Region, Grantee shall maintain MOUs with the other COPSD Grantees to ensure
that COPSD services are available to all clients of System Agency -funded mental
health and SUD treatment providers.
B. Service Delivery
Grantee shall:
1. Ensure that services to adult and youth clients, as defined in the SUD Program Guide,
are age -appropriate and are provided by staff within their scope of practice.
2. Provide all services in a culturally, linguistically, and developmentally appropriate
manner for clients, families, and/or significant others.
3. Develop a policy and procedure and have them available for system agency review on
staff training to ensure that information is gathered from clients in a respectful, non-
threatening, and culturally competent manner.
4. Adhere to TAC rules related to Access to Services for COPSD, Additional
Requirements for COPSD Programs and, Specialty Competencies of Staff Providing
Services to Clients with COPSD.
5. Conduct and document a full substance use disorder and mental health assessment
(separate or integrated) within three individual service days of admission to services
unless completed prior to admission. If the assessment identifies a potential mental
health or substance use disorder problem, Grantee shall offer the client appropriate
mental health and/or substance use disorder services either internally or through
referral. Mental health treatment shall be provided by a facility or qualified person
authorized to provide such services.
6. Document in CMBHS on the client's treatment plan both mental health problems
and SUD problems with a goal, objectives and strategies documented for each
problem.
7. Adhere to TAC related to Treatment Planning of Services to Clients with COPSD.
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HHSC Contract No. HHS000779500006
Amendment No. 2
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8. Document in CMBHS the treatment plan within five (5) service days of admission.
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
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9. At a minimum, Grantee shall conduct a treatment plan review every three months.
10. Provide and document in CMBHS services that assist in client stabilization, including
Motivational Interviewing, referrals, case management and other counseling as
indicated by the treatment plan based on the clinical assessment.
11. Address both psychiatric and substance use disorders simultaneously and assist clients
in obtaining available services they need and choose, including self-help groups.
Services shall be provided within established practice guidelines for this population.
12. Provide individual counseling and case management as indicated below:
i. Individual Counseling comprises counseling methods from qualified staff
that assist clients in processing feelings in the area of gaining access to and
remaining engaged in substance use disorder or mental health services or
obtaining access to both.
ii. Case Management comprises services that assist and support the client in
developing skills to gain access to needed medical, social, educational, and
other services essential to meeting basic human needs.
13. Provide a minimum of one hour per week of documented service in CMBHS to each
client.
14. In those instances where the client is receiving multiple services from various other
providers in the community, Grantee shall make reasonable efforts to collaborate with
these providers to avoid duplication of services specifically from the mental health
and substance use disorder fields.
15. Adhere to Texas Administrative Code, regarding Client Rights including Client Bill
of Rights, Client Grievances, and Abuse, Neglect, and Exploitation.
16. Provide overdose prevention and reversal education to all clients.
17. Specific overdose prevention activities shall be conducted with clients with opioid use
disorders and those clients that use drugs intravenously. Grantee will directly provide
or refer to community support services for overdose prevention and reversal education
to all identified at risk clients prior to discharge. Grantee will document all overdose
prevention and reversal education in CMBHS.
18. Ensure access to adequate and appropriate medical and psychosocial tobacco cessation
treatment as follow:
i. Assess all clients for tobacco use and clients seeking to cut back or quit.
ii. If the client indicates wanting assistance with cutting back or quitting, the
client will be referred to appropriate tobacco cessation treatment.
19. Document the client -specific information that supports the reason for discharge listed
on the discharge report. A Qualified Credentialed Counselor (QCC) shall sign the
discharge summary. A client's treatment is considered successfully completed, if both
of the following criteria are met:
i. Client has completed the clinically recommended number of treatment units
(either initially projected or modified with clinical justification) as indicated in
CMBHS.
ii. All problems on the treatment plan have been addressed. Grantee shall use the
Treatment Plan component of CMBHS to create a final and completed
treatment plan version.
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
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iii. Problems designated as "treat" or "case manage" status shall have all
objectives resolved prior to successful discharge.
iv. Problems that have been "referred" shall have associated documented referrals
in CMBHS.
V. Problems with "deferred" status shall be re -assessed. Upon successful
discharge, all deferred problems shall be resolved, either through referral,
withdrawal, treatment, or case management with clinical justification reflected in
CMBHS, through the Progress Note and Treatment Plan Review Components.
vi. "Withdrawn" problems shall have clinical justification reflected in CMBHS,
through the Progress Note and Treatment Plan Review Components.
20. Document in CMBHS all Referrals and Referral Follow-ups. Mental health referrals
must be documented and followed up.
21. Grantee shall report the Daily Capacity Management Report Monday through Friday
in (CMBHS) by 11:00 a.m. Central Time. For example: Monday's daily attendance
may be reported on Tuesday and Friday's attendance may be reported on the following
Monday.
22. Grantee will adhere to Wait List requirements. The Waiting List is for individuals who
cannot enter services within one week of request.
i. Upon determining the appropriate level of care, Grantee will make a waiting
list entry in CMBHS that details the service type the individual is waiting for
and the priority population designation of the individual.
ii. Arrange for appropriate services in another treatment facility or provide access
to interim services as indicated within 48 hours when efforts to refer to other
appropriate services are exhausted.
iii. Have a written policy on waiting list management that defines why and how
individuals are removed from the waiting list for any purpose other than
admission to treatment.
iv. Ensure eligible individuals who cannot be admitted within one week of
requesting services must be placed on the CMBHS waiting list.
V. Upon admission, treatment Contractor will close the waiting list entry,
indicating the date of admission as the waiting list end date.
vi. Ensure, either directly or through referral, that individuals waiting for
admission receive interim services as required by SAMHSA Block Grant
requirements.
vii. Document weekly contact with all individuals on its waiting list
viii. Notify Substance Use Disorder (Substance Use Disorder(c4,hhs.texas. gov) or
System Agency Program Specialist for assistance to ensure immediate
admission to priority populations other appropriate services and proper
coordination when appropriate.
SECTION III: STAFF COMPETENCY AND REQUIREMENTS
Grantee shall ensure the following:
A. All personnel shall receive the training and supervision necessary to ensure
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
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compliance with System Agency rules, provision of appropriate and individualized
treatment, and protection of client rights, health, safety, and welfare.
B. All COPSD staff shall have at minimum two hours of training annually on working
with persons in the target population.
C. Adhere to TAC related to Specialty Competencies of Staff Providing Services to
Clients with COPSD. Ensure that all COPSD staff have access to additional training
annually that allows staff to maintain up-to-date competencies through governing or
supervisory boards for the respective disciplines. Additional training can be found at
National Association for Alcoholism and Drug Abuse Counselors (NAADAC)
website. https://www.naadac.orgleducation
D. Ensure that all direct care staff receive a copy of the service requirements within this
statement of work.
E. Individuals responsible for planning, directing, or supervising treatment services shall
be QCCs.
F. Grantee shall have a clinical program director known as "Program Director" with at
least two years of post- QCC licensure experience providing substance use disorder
treatment. Substance use disorder counseling shall be provided by a QCC. All
counselor interns shall work under the direct supervision of a QCC.
G. Within 90 days of hire and prior to providing service delivery, clinical staff shall have
specific documented training in the following:
l . Motivational Enhancement Therapy or motivational interviewing techniques;
2. Trauma Informed Care;
3. Cultural Competency;
4. Harm Reduction Trainings;
5. Health Insurance Portability and Accountability Act (HIPAA) and 42 Code of Federal
Regulations (CFR) Part 2 training
6. State of Texas co-occurring psychiatric and substance use disorder (COPSD)
training located at the following website www.centralizedtraining.com
H. Ensure all direct care staff complete annual education on HIPAA and 42 CFR Part 2
training.
I. Licensed Chemical Dependency Counselors shall recognize the limitations of the
licensee's ability and shall not provide services outside the licensee's scope of practice
or licensure or use techniques that exceed the person's license authorization or
professional competence.
J. Individual counseling shall be provided by a Licensed Practitioner of the Healing Arts
or a QCC. A QCC shall practice within their scope of practice. As outlined in the 25
TAC Chapter 140, Subchapter I § 140.400.
K. Ensure that a Licensed Professional Counselor Intern (LPC-I), Licensed Marriage and
Family Therapist Associate (LMFT-A) and Licensed Master Social Worker(LMSW)
intending to obtain their LCSW (Licensed Clinical Social Worker) in the State of
Texas, may provide a mental health diagnosis and COPSD mental health counseling
as long as the following criteria is met:
1. Confirmation that LPC-I, LMFT-A and LMSW are registered with each of the
respective licensing boards with a board -approved supervisor and will ensure
HHSC Solicitation No. IT]TS0007795
HHSC Contract No. HHS000779500006
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that LPC-I, LMFT-A and LMSW are under supervision when providing
counseling under the Contract.
2. An LPC-I may provide individual COPSD counseling services. Refer to 22
TAC, Chapter 681, Subchapter B.
3. A LMSW may practice clinical social work in an agency employment setting
under clinical supervision, under a board -approved supervision plan, or under
contract with an agency when under a board -approved clinical supervision
plan. The LMSW under a board supervision plan may provide individual
COPSD counseling services under the Contract. Refer to 22 TAC, Chapter
781.
4. An LMFT-A may provide individual COPSD counseling services. Refer to 22
TAC, §801.42.
L. Case Management shall be provided face-to-face and one-on-one by:
1. An individual who has been credentialed by the LMHA as a QMHP; or,
2. An individual who:
i. has a bachelor's degree from an accredited college or university
with a major in psychology, social work, medicine, nursing,
rehabilitation, counseling, sociology, human growth and
development, physician assistant, gerontology, special education,
educational psychology, early childhood education, or early
childhood intervention, or
ii. is a registered nurse.
M. Grantee shall train COPSD staff responsible for providing direct services using
Substance Abuse Mental Health Services Administration (SAMHSA) Treatment
Improvement Protocol (TIP) — Comprehensive Case Management to as a guideline.
https:Hstore.samhsa.gov//product/TIP-27-Comprehensive-Case-
Management-for-Substance-Abuse-Treatment/SMA 15-4215
N. Grantee shall develop a post -training test and provide certificates of completion, both
of which will confirm that COPSD staff demonstrate competency in the following
areas:
1. Knowledge of the location and types of local community resources;
2. Making referrals in the community in which the client resides;
3. Development of person -centered treatment plans;
4. Discharge planning;
5. Documentation of service delivery; and
6. Ensuring services are culturally, linguistically, and developmentally
appropriate.
A. Grantee shall submit required reports of monitoring activities to System Agency by
the applicable due date outlined below. The following reports must be submitted to
System Agency through, CMBHS, another HHSC submission system, or by email to
the SUD Mailbox, SUD.ContractsOhhs.texas. gov., by the required due date and
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
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report name described in Table 1: Submission Requirements.
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
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B. Reports submitted to the SUD Mailbox shall utilize the following naming convention
in the email subject line:
[FY for Deliverable] Deliverable [Name of Deliverable] SA/COPSD [Contract
No.]
C. Grantee is required to maintain access to CMBHS for the term of this contract.
D. Grantee shall submit all documents listed in Table 1 by the Due Date stated.
E. Grantee will note that if the due date is on a weekend or holiday, the due date isthe
following business day.
F. Grantee shall submit a quarterly match report, which documents Grantee's
compliance to contribute five percent match. The report is due on the 15th of the
month, following the closure of the state quarter.
G. Grantee shall submit annual Contract Closeout documentation each fiscal yearwith
a final contract closeout due by 45 days after contract end date.
H. Grantee shall submit a CMBHS Security Attestation Form on or before September
151h and March 15`h, each fiscal year.
I. Grantee's duty to submit documents will survive the termination or expiration ofthis
Contract.
J. System Agency will monitor Grantee's performance of the requirements in
Attachment A and Attachment B, and compliance with the Contract's terms and
conditions.
Table 1: Submission Requirements
Requirement
Deliverable
Due Date
Submission System
(Report Name)
Section IV
Quarterly Match
Each FY.
SUD Mailbox:
Report
Quarterl^
SUD.Contracts@hhs.texas.gov
Q 1: December 15th
Q2: March 15th
Q3: June 15th
Q4: September 15th
Section IV
FY Closeout
Each FY:
SUD Mailbox:
documents
October 151h
SUD.Contracts@hhs.texas.gov
Section IV
Final Closeout
By 45 days after
SUD Mailbox:
documents
contract end date.
SUD.Contracts@hhs.texas.gov
HHSC Solicitation No. HHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
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Section V
CMBHS
Each FY:
SUD Mailbox:
Security Attestation
September 15th &
SUD.Contracts@hhs.texas.gov
Form and list of
March 151h
authorized users
SECTION V: CLINICAL MANAGEMENT FOR BEHAVIORAL HEAj,TH SERVICES
(CMBHS) SYSTEM MINIMUM REQUIREMENTS
Grantee Shall:
A. Designate a Security Administrator and a back-up Security Administrator. The Security
Administrator is required to implement and maintain a system for management of user
accounts/user roles to ensure that all the CMBHS user accounts are current.
B. Establish and maintain a security policy that ensures adequate system security and protection
of confidential information.
C. Notify the CMBHS Help -desk within 10 business days of any change to the designated
Security Administrator or the back-up Security Administrator.
D. Ensure that access to CMBHS is restricted to only authorized users. Grantee shall, within 24
hours, remove access to users who are no longer authorized to have access to secure data.
E. In addition to CMBHS Helpdesk notification, Grantee shall submit a signed CMBHS Security
Attestation Form and a list of Grantee's employees and contracted laborers authorized to have
access to secure data. The CMBHS Security Attestation Form shall be submitted
electronically on or before the 151h day of September and March 151h, each fiscal year.
F. Attend System Agency training on CMBHS documentation.
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HHSC Contract No. HHS000779500006
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ATTACHMENT B
PROGRAM SERVICES & UNIT RATES
(AUGUST 2023)
A. Contract is funded with the United States Health and Human Services (HHS), the Substance
Abuse and Mental Health Services Administration (SAMSHA), Substance Use Prevention
Treatment Recovery Services (SUPTRS) Block Grant, Assistance Listing Number (ALN)
93.959 and System Agency General Revenue.
B. Compliance is required with the following provisions of Code of Federal Regulation (CFR):
1. SUPTRS Block Grant: 45 CFR Part 96, Subpart C, link: 45 CFR Part 96.
2. Federal Uniform Grant Guidance for Title 2, Grants and Agreements, Subtitle A. Office
of Management and Budget Guidance for Grant and Agreements, Chapter II Office of
Management and Budget Guidance, Part 200 Uniform Administrative Requirements
Cost Principles, and Audit Requirements for Federal Awards, link:_
https://www.ecfr.gov/current/title-2/subtitle-A/ch+96apter-II. For additional guidance
regarding the Federal Uniform Grant Guidance please see also:-
https://www.hhs.texas.izov/business/grants/federal-uniform- rg ant-y,uidance
C. Compliance is required with Texas Grant Management Standards, located at Texas
Comptroller of Public Accounts, link: https:Hcomptroller.texas.gov/purchasing/ rg ant-
mana ement/
D. Funding
1. System Agency's share of total reimbursements is not to exceed $318,800.00 for the period
of February 01, 2022 through August 31, 2025, as further specified and allocated by fiscal
year (FY) in Article IV, Budget of the Contract Signature Document.
2. The required Grantee match for the same period is $15,940.00. Grantee is required to
contribute five (5%) matching of funds. All funding from the SUPTRS Supplemental
funding (HR133 and/or COVID-19) do not require the matching of funds and is excluded
from the match calculations.
E. Claims and Payment Requirements:
1. Grantee shall submit claims in CMBHS after services are rendered; no later than monthly.
2. After the closure of each fiscal year, System Agency shall conduct contract close-out
activities. Grantee shall ensure all claims for each state fiscal year (September — August)
are submitted in CMBHS by October 15". Claims submitted after October 151h may be
HHSC Solicitation NoHHS0007795
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denied.
All claims for September service period of the current fiscal year must be submitted by
October 15th. Claims submitted after this date may be denied due to the grant budget
period being closed.
4. System Agency may request additional supportive documentation to support the claims.
All requests for additional information shall be provided by the deadline requested
F. Except as indicated by the CMBHS financial eligibility assessment, Grantee shall accept
reimbursement or payment from System Agency as payment in full for services or goods
provided to clients or participants; and Grantee shall not seek additional reimbursement or
payment for services or goods, to include benefits received from federal, state, or local sources,
from clients or participants.
G. Budget Program Adjustment (BPA) Requirements
Grantee may request revisions to the approved service group distribution of funds
budgeted in the Service Type/Numbers Served/Capacity/Funding Amounts Chart, by
completing a Budget Program Adjustment (BPA) Form and submitting to the System
Agency Contract Manager and the SUD Mailbox at SUD.Contracts@hhs.texas.gov.
2. System Agency will review the request to determine if the request is allowable under the
RFA, if applicable, and if the request is approved or denied. The estimated timeline for
System Agency to review and provide written communication on the results of the BPA
request is 30 days from receiving an accepted form. Any revisions to the distribution of
funds will result in revised numbers served and/or capacity requirements.
3. Each Fiscal Year (FY), the deadlines to submit a BPA is March 1 St.
H. Any unexpended balance associated with any other System Agency Contract may not be
applied to this System Agency Contract.
I. System Agency funded capacity is defined as the stated number of clients who will be
concurrently served as determined by this Contract.
I Service Unit Rates
The unit rates for the service charts referenced in Section N of this Attachment are located
at the System Agency Substance Use Disorder Service Provider's webpage, under Forms,
document name: Treatment Rate Sheet, the link to the webpage is below. All unit rates
are subject to change and contingent on available funding.
https:Hhhs.texas. gov/doing-business-hhs/provider-portals/behavioral-health-services-
providers/substance-use-disorder-service-providers
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If the link to the webpage and/or location of the applicable unit rate document changes,
System Agency will provide Grantee notice through a broadcast message via email.
2. If unit rates are adjusted in accordance with Section J.1. of this Attachment., System
Agency will provide Grantee notice through a broadcast message via email. All broadcast
messages will be maintained in Grantees Contract file, and document the following:
a. Treatment Program/Service Type unit rate adjustments;
b. Treatment Program/Service Type unit rate adjustments effective date;
c. Treatment Program/Service Type method for receiving payments for the unit rate
adjustment, in accordance with Section J.3. of this Attachment.
There may be a delay between the effective date of the rate adjustment and those updated
rates being reflected in CMBHS. In the event of a difference in the posted adjusted rate and
the rate in CMBHS, the posted rate controls and payment will be adjusted as described in
Section J.4. of this Attachment.
4. The System Agency effective date of the rate adjustment will determine the method(s) to
implement the unit rate adjustment, as follows:
a. During the fiscal year close-out, System Agency may conduct reconciliation to extract
paid claims data for services provided by Grantee during the unit rate adjustment
approval period. System Agency may calculate the difference between Grantee's
payment utilizing the unit rate in CMBHS versus the revised unit rate. System Agency
will thereafter issue Grantee a final reconciliation payment for the difference between
the two service unit rates. Grantee's fiscal year payment may not exceed the total fiscal
year allocation set forth in Contract Signature Document, Section IV and/or
Amendments documenting revisions to FY allocations.
b. System Agency may revise the service unit rates in CMBHS to ensure all service claims
during the approved service period may be reimbursed at the revised rate.
c. System Agency reserves the right to utilize different method(s) to process unit rate
adjustments.
d. Method(s) used to process unit rate adjustments will be described in the broadcast
message in Section J.1. of this Attachment.
K. Clinic numbers must be approved by the System Agency Contract Manager before billing can
occur. The Clinic Change Request Form is located at the System Agency Substance Use
Disorder Service Provider's webpage, under Forms, document name: Clinic Request Form,
the link to the webpage is below:
https:Hhhs.texas.izov/doing-business-hhs/provider-portals/behavioral-health-services-
providers/substance-use-disorder-service-providers.
L. Service Types with no associated amount will be paid from the preceding Service Type with
an associated amount.
HHSC Solicitation NoHHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
3
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
M. Reimbursement of Allowable Costs for State Fiscal Year 2022 and State Fiscal Year 2023:
Grantees may be eligible to receive additional payments for fiscal years 2022 and 2023 for
COVID 19-related costs incurred for covered services that were not included under the fee -for
service payment reimbursement mechanism.
Additional payments will only be made upon written approval from System Agency. The
agency does not guarantee the additional payments will cover all COVID 19-related costs. In
no event will the total amount paid to any Grantee exceed the contract values as specified in
Article IV, Budget, of the Contract Signature Document for the associated fiscal year.
At its sole discretion, System Agency will determine additional payment amounts by applying
inflationary and/or market adjustment factors, such as the Consumer Price Index. Additional
payments will be based on Grantee's actual claim services provided and submitted to System
Agency for reimbursement through CMBHS no later than October 15th of each fiscal year.
Additional payments shall comply with applicable provisions within Title 2 of the Code of
Federal Regulations, Part 200 (Uniform Administrative Requirements, Cost Principles, and
Audit Requirements for Federal Awards), and Title 45 of the Code of Federal Regulations Part
96 (Block Grants), and the Texas Grant Management Standards (TxGMS).
Additional payments will be made at the sole discretion of System Agency and are subject to
availability of funds.
N. The Service Types, Numbers Served, Capacity, and Funding Amounts in the table below are
approved by System Agency. Grantee shall perform the required services set forth in
Attachment A of this Contract in accordance with the following cost categories:
HHSC Solicitation NoHHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
4
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
SERVICE TYPE/NUMBERS SERVED/CAPACITY/FUNDING AMOUNTS
Fiscal Year 2023 Service Chart
Number
Service Type
Served
Capacity
Amount
Co-occurring Psychiatric & Substance
70
8
$79,700.00
Abuse Disorders COPSD
Co-occurring Psychiatric & Substance
Abuse Disorders COPSD - Adult
Co-occurring Psychiatric & Substance
Abuse Disorders COPSD - Youth
Fiscal Year 2024 Service Chart
Number
Service Type
Served
Capacity
Amount
Co-occurring Psychiatric & Substance
70
8
$79,700.00
Abuse Disorders COPSD
Co-occurring Psychiatric & Substance
Abuse Disorders (COPSD) - Adult
Co-occurring Psychiatric & Substance
Abuse Disorders COPSD - Youth
Fiscal Year 2025 Service Chart
Number
Service Type
Served
Capacity
Amount
Co-occurring Psychiatric & Substance
70
8
$79,700.00
Abuse Disorders (COPSD
Co-occurring Psychiatric & Substance
Abuse Disorders COPSD - Adult
Co-occurring Psychiatric & Substance
Abuse Disorders COPSD - Youth
HHSC Solicitation NoHHS0007795
HHSC Contract No. HHS000779500006
Amendment No. 2
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
TEXAS Form 8040-A
August 2022-E
`V Health and Human
Services Federal Funding Accountability and Transparency Act (FFATA)
Certification Form
The certifications enumerated below represent material facts upon which HHSC relies when reporting information to the federal government
required under federal law. If HHSC later determines that the contractor knowingly rendered an erroneous certification, HHSC may pursue all
available remedies in accordance with Texas and U.S. laws. The signer further agrees that they will provide immediate written notice to HHSC
if at any time they learn that any of the certifications provided for below were erroneous when submitted or have since become erroneous by
reason of changed circumstances. Note: If the signer cannot certify all of the statements contained in this section, they must provide written
notice to HHSC detailing which of the below statements they cannot certify and why.
Did your organization have a gross income, from all sources, of less than $300,000 in your previous tax year?
Q Yes — Skip questions A, B and C and continue to section D. ® No — Answer questions A and B.
A. Certification Regarding Percent of Annual Gross from Federal Awards
Did your organization receive 80% or more of its annual gross revenue from federal awards during the preceding fiscal year?
Q Yes ® No — Skip question C.
B. Certification Regarding Amount of Annual Gross from Federal Awards
Did your organization receive $25 million or more in annual gross revenues from federal awards in the preceding fiscal year?
® Yes Q No — Skip question C.
If your answer is Yes to both questions A and B, you must answer question C.
If your answer is No to either question A or B, skip question C and continue to section D.
C. Certification Regarding Public Access to Compensation Information
Does the public have access to information about the highly compensated officers/senior executives in your business or organization (including
parent organization, all branches and all affiliates worldwide) through periodic reports filed under Section 13(a) or 15(d) of the Securities
Exchange Act of 1934 (15 U.S.C. 78m(a), 78o(d)) or Section 6104 of the Internal Revenue Code of 1986?
e Yes Q No — Provide the names and total compensation of the top five highly compensated officers/senior executives.
Name of Officer or Senior Executive
Total Compensation
1.
2.
3.
4.
5.
D. Signatures
As the duly authorized representative (signer) of the contractor, I hereby certify that the statements made by me in this certification form are
true, complete and correct to the best of my knowledge.
EDoouSlgned by:
�� P � August 28, 2023
i781 FF92cl146D...
Signature of Authorized Representative Date
Printed Name of Authorized Representative imayor
Title of Authorized Representative
Tray Payne
Legal Name of Contractor I Unique Entity Identifier
City of Lubbock
Applicable HHSC Contract No.(s):
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29EO6F
TEXAS
o PCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
LLGoServices
Section 1: Contract Information
New Contract Number
❑ HHS000779500006
Amendment Number
2
New Work Order Number
❑
Amendment Number
❑
Contractor Legal Business Name:
CITY OF LUBBOCK
Total Contract Value (Including Renewals)
$334,740.00
Note: Contract value is defined as the estimated dollar amount that the agency may be obligated to pay
pursuant to the contract and all executed and proposed amendments, extensions and renewals of the contract.
Requesting Agency/Program
HHSC MSS-SUDCMU
Contract Manager Name
Cristina Bunyard
Contract Manager Email
cristina.bunyard@hhs.texas.gov
Contract Manager Phone
N/A
Purchaser/Buyer Name
ApprovalsSection 2: CAPPS
approversThis section contains all contract -specific
required approvers listed in Section 2 must include
contracts. All contract -specific approvers, exceptfor
Financials. CAPPS approvals must occur in
Purchaser/Buyer Email Purchaser/Buyer Phone
Program...
the contract manager, program staff, and legal approval; legal approval may be provided byernailfor boderplate template
the contract signatory who will review and approve in DocuSign, Must be listed in this section to approve the contract in
the order listed
below.CAPPS
Is this a legal approved boilerplate template? ® Yes ❑ No If "Yes" attach Proof of Approval
Approver Title
Approver Name
Approver E-mail Address
1.
Contract Analyst ICristina
Bunyard
cristina.bunyard@hhs.texas.gov
2.
Contract Administration M
Angela Perkins
Fngela.perkins@hhs.texas.gov
3•
Legal
FFescenmeyer,Megan
Megan.FescenmeyerO1@hhs.texas.gov
4.
5.
6.
7.
8.
[
9.
—_
10.
11.
Effective 10/23/2017 - 1 - Revised 01/13/2022
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
TEXAS
o PCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
U.0 Services
DocuSign Routing Path Begins
Section 3: Internal Required DocuSign Review and Approvals
In addition to the approvals in Section 2 the following approvers are needed consistent with the chart below.
HHSC Contracts
Approver Name E-mail Address
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
System Contracting Director
Andy Marker
Edward.Marker@hhs.texas.gov
17.
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
System Contracting Director
Andy Marker
Edward. Marker@hhs.texas.gov
Office of Chief Counsel
Karen Ray
Karen.Ray@hhs.texas.gov
01G Contracts
A110,000,000upto$i
Approver
Name E-mail Address
Chief Financial Officer
Trey Wood Trey.Wood@hhs.texas.gov
Chief Financial Officer
Trey Wood
Trey.Wood@hhs.texas.gov
System Contracting Director
Andy Marker
Edward. Marker@hhs.texas.gov
Office of Chief Counsel
Karen Ray
Karen. Ray@hhs.texas.gov
DSHS Contracts
0i0 000
Approver Name E-mail Address
System Contracting Director
Andy Marker
Edward.Marker@hhs.texas.gov
DSHS General Counsel
Cynthia Hernandez
Cynthia.Hernandez3@hhs.texas.gov
System Contracting Director Andy Marker Edward. Marker@hhs.texas.gov
Office of Chief Counsel
Karen Ray
Karen. Ray@hhs.texas.gov
Effective 10/23/2017 .2. Revised 01/13/2022
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29EO6F
TEXAS
o PCS 515 CONTRACT ROUTING AND APPROVAL REQUEST Health and Human
U.I&
Services
SectionDocuSign Signatories
Signatory
Name
E-mail Address
Contractor Signature Authority
Tray Payne
TrayPayne@mylubbock.us
Additional Contractor Signature
Authority*
Contractor Signature cc
Gloria Diaz
gdiaz@mylubbock.us
HHS Signature Authority
Swan,Roderick
Roderick.Swan@hhs.texas.gov
HHS Signature Authority cc
FSA Mailbox
SUD.Contracts@hhs.texas.gov
General Inbox cc
Cristina Bunyard
Fcristina.bunyard@hhs.texas.gov
* If adding an additional contractor signature authority, please provide instructions on which documents need to be completed by this individual.
Please cc: Katherine Wells at: kwells@mylubbock.us
Effective 10/23/2017 - 3 - Revised 01/13/2022
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
TEXAS
`o PCS S1 S CONTRACT ROUTING AND APPROVAL REQUEST `� Health and Human
U.0 Services
INSTRUCTIONS
PURPOSE
To direct HHS contracts, work orders, amendments, renewals, and extensions through the routing and approval process.
WHEN TO PREPARE THIS FORM
This form shall be completed for any document requiring CAPPS Financials approval routing and for DocuSign contract signature routing.
Program area shall adhere to any HHS Circular-046 requirements to complete the form prior to submission to Procurement and
Contracting Services Quality Assurance ("PCS QA").
PROCEDURE TO COMPLETE PCS 515
Section 1: To be completed by Program.
This section contains necessary contract information.
Section 2: To be completed by Program.
This section contains all contract -specific approvers as designated by Program. These individuals will be inserted into the CAPPS
Financials approval process. The minimum required approvers listed in Section 2 must include the contract manager, program staff, and
legal approval. All contract -specific approvers, except for the contract signatory who will review and approve in DocuSign, must
be listed in this section to approve the contract in CAPPS Financials. CAPPS approvals must occur in the order listed in Section 2.
DocuSign Routing Path Begins
Section 3: Required Approvals.
This section contains all required Office of Chief Counsel and Chief Financial Officer approvals based on contract value.
Section 4: To be completed by Program.
This section shall contain all required contract signatory information. These individuals will be inserted into the DocuSign routing path.
Effective 10/23/2017 - 4 - Revised 01/13/2022
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29EO6F Contracts w > Create Contracts and Documents • > Contract Entry
OPACL-Eo weicome 00000232016 logged on FSPRD
Document Approval Status
SetlD HHSTX
Supplier CITY OF LUBBOCK
Review/Edit Approvers
Contract Document Approval
:Approved
Contract Document Approval
Contract ID HHS000779500006
ViewlHide Comments
Approved Approved
Bunyard,Cristina Ansald Perlcins,Angela C
ve filontrad ManagerlBuyer Inserted Approver
W02P23-11:37 AAA D&Tl2d23 - 9:58 Pill
Comment History
Submit for ApprovaI
Return to Document Management
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
From: Ford.Laura (HHSC)
To: Driscoll.James (HHSC); Perkins.Angela (HHSC)
Cc: Cruz.Lisa (HHSC): Moore.Mary (HHSC/DSHS): Molenaar.Jennifer (H
Zarrella. Danielle (HHSC); HHSC SUD Contracts
Subject: Legal Approval: BP 06 COPSD
Date: Thursday, July 13, 2023 1:04:55 PM
Attachments: 3. Attach B Program Services Unit Rates System Contractina Edit
t. COPSD Signature Page - Remove funds7.10.23 System Contracti
1. COPSD Signature Paae - No funding chanae57.10.23 System Cor
5. Attachment H. FFATA (8).Ddf
image001.Dna
Hello James and Angela
Please find the legally approved boilerplate for COPSD.
Please let me know if there are any questions.
Thanks
Laura Ford I Director
Substance Use Disorder Contract Management Unit
Behavioral Health Contract Operations
Work cell: 806.252.4683
Email: laura.fordahhs.texas.gov
TEXAS
Health and Human
Services
If you are an entity interested in doing business with the state, please direct your inquiry to the Electronic State
Business Daily (ESBD) to search for funding opportunities with HHSC using the following link:
http://www.txsmarthuy.com/sp
Confidentiality Statement: The contents of this e-mail message and any attachments are confidential and are
intended solely for addressee. The information may also be legally privileged. This transmission is sent in trust,
for the sole purpose of delivery to the intended recipient. If you have received this transmission in error, any use,
reproduction or dissemination of this transmission is strictly prohibited. If you are not the intended recipient,
please immediately notify the sender by reply e-mail or phone and delete this message and its contents (including
attachments).
From: Fescenmeyer, Megan (HHSC) <Megan.Fescenmeyer0l@hhs.texas.gov>
Sent: Wednesday, July 12, 2023 2:08 PM
To: Ford,Laura (HHSC) <Laura.Ford@hhs.texas.gov>
Cc: Zarrella,Danielle (HHSC)<Danielle.Zarrella@hhs.texas.gov>; Molenaar,Jennifer (HHSC/DSHS)
<Jennifer.Molenaar@hhs.texas.gov>; HHSC SLID Contracts <SUD.Contracts@hhs.texas.gov>
Subject: RE: For Review and Approval by 7/12/23: BP Status Inquiry: Boilerplate 06 CCPSD
Hi Laura and all,
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
Please find attached approved packet by myself and my leadership. The
sig docs and budget have been revised. No changes to the SOW. Let me
know if there are any questions. Friendly reminder that so long as there no
changes to the approved boilerplate content, you do not need to send to
me for approval in CAPPS FIN for each individual amendment.
Thanks,
Megan
From: Ford,Laura (HHSC) <Laura.Ford(@hhs.texas.gov>
Sent: Monday, July 10, 2023 11:54 PM
To: Fescenmeyer,Megan (HHSC) <Megan. Fescenmeyer0l(@hhs.texas.gov>
Cc: Zarrella, Danielle (HHSC) <Danielle.Zarrella(@hhs.texas.gov>; Molenaar,Jennifer (HHSC/DSHS)
<Jennifer.Molenaar(@hhs.texas.gov>; HHSC SUD Contracts <SUD.Contracts(@hhs.texas.gov>
Subject: For Review and Approval by 7/12/23: BP Status Inquiry: Boilerplate 06 COPSD
Importance: High
Hello Megan
Please find attached all documents as part of the boilerplate(BP) submission for your
review and approval. Please find change from BP submission on 5/16/23 regarding
Attachment E-1 Supplemental Terms and Conditions as no revision will be needed as
part of the boilerplate. The Amendment Sign Page for No funding Changes and
Remove funds have been revised to remove the revision to Attachment E-1 indicated
by strikeouts.
Respectfully request review and approval of the boilerplate for COPSD by 7/12/23.
Please let me know if previous review had been completed on the boilerplate
documents as I could not locate email noting your review but perhaps I was not
included in the email or missed the email.
Please let me know if there are any questions or anything else that is needed for this
request.
Thank You,
Laura Ford I Director
Substance Use Disorder Contract Management Unit
Behavioral Health Contract Operations
Work cell: 806.252.4683
Email: laura.ford(t�hhs.texas.gov
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
TEXAS
�V Health and Human
Services
If you are an entity interested in doing business with the state, please direct your inquiry to the Electronic State
Business Daily (ESBD) to search for funding opportunities with HHSC using the following link:
httg://www.txsmarthuy.com/so
Confidentiality Statement: The contents of this e-mail message and any attachments are confidential and are
intended solely for addressee. The information may also be legally privileged. This transmission is sent in trust,
for the sole purpose of delivery to the intended recipient. If you have received this transmission in error, any use,
reproduction or dissemination of this transmission is strictly prohibited. If you are not the intended recipient,
please immediately notify the sender by reply e-mail or phone and delete this message and its contents (including
attachments).
From: Zarrella,Danielle (HHSC) <Danielle.Zarrella(@hhs.texas.gov>
Sent: Saturday, July 8, 2023 8:42 AM
To: Ford Laura (HHSC) <Laura.Ford(@hhs.texas.gov>; Fescenmeyer, Megan (HHSC)
<Megan.Fescenmeyer0ll@ hhs.texas.gov>
Cc: Molenaar,Jennifer (HHSC/DSHS) <Jennifer.Molenaar(@hhs.texas.gov>; HHSC SUD Contracts
<SUQ.Contracts(@hhs.texas.gov>
Subject: RE: BP Status Inquiry: Boilerplate 06 COPSD
Good Morning Megan,
Following up on this request. I am the assigned CM for the COPSD Boiler Plate. Please send
your comments/edits to me once your review is complete.
Thank you!
DANIELLE ZARRELLA, CTCM I Contract Manager
Substance Use Disorder Contract Management Unit
Behavioral Health Services
909 West 45th St. I Austin, Texas 78751
Email: Danielle.Zarrella(@hhs.texas.gov
TEXAS
Qiy Health and Human
Services
Confidentiality Statement: The contents of this e-mail message and any attachments are confidential and are intended solely
for addressee. The information may also be legally privileged. This transmission is sent in trust, for the sole purpose of
delivery to the intended recipient. If you have received this transmission in error, any use, reproduction or dissemination of
this transmission is strictly prohibited. If you are not the intended recipient, please immediately notify the sender by reply e-
mail or phone and delete this message and its contents (including attachments).
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29EO6F
From: Ford,Laura (HHSC) <Laura.Ford(@hhs.texas.gov>
Sent: Sunday, July 2, 2023 9:54 PM
To: Fescenmeyer, Megan (HHSC) <Megan. Fescenmeyer0ltahhs.texas.gov>
Cc: Zarrella,Danielle (HHSC) <Danielle.ZarrellaPhhs.texas.gov>; Molenaar,Jennifer (HHSC/DSHS)
<Jennifer.Molenaarl@hhs.texas.gov>; HHSC SUD Contracts <SUQ.Contracts(@hhs.texas.gov>
Subject: BP Status Inquiry: Boilerplate 06 COPSD
Importance: High
Hello Megan
Just wanted to touch base on review and approval of the boilerplate
submitted on 5/16/23 by Nicole Acclis, Director. Nicole completed the
submission yet she is out on extended leave and is this boilerplate is now
assigned to Danielle Zarella, Contract Manager.
. Boilerplate 06 COPSD
Please let us know if there are any questions or anything that is needed on
our end.
Thanks,
Laura Ford I Director
Substance Use Disorder Contract Management Unit
Behavioral Health Contract Operations
Work cell: 806.252.4683
Email: laura.ford@hhs.texas.gov
TEXAS
Health and Human
Services
If you are an entity interested in doing business with the state, please direct your inquiry to the Electronic State
Business Daily (ESBD) to search for funding opportunities with HHSC using the following link:
http://www.txsmarthuy.com/sg
Confidentiality Statement: The contents of this e-mail message and any attachments are confidential and are
intended solely for addressee. The information may also be legally privileged. This transmission is sent in trust,
for the sole purpose of delivery to the intended recipient. If you have received this transmission in error, any use,
reproduction or dissemination of this transmission is strictly prohibited. If you are not the intended recipient,
please immediately notify the sender by reply e-mail or phone and delete this message and its contents (including
attachments).
DocuSign Envelope ID: C0974882-8F74-4A20-87A8-62CBAA29E06F
Certificate Of Completion
Envelopeld: C09748828F744A2087A862CBAA29EO6F
Subject: Amending $334,740.00; HHS000779500006; CITY OF LUBBOCK A-2 ; HHSC MSS-SUDCMU
Procurement Number:
Source Envelope:
Document Pages: 28 Signatures: 5
Certificate Pages: 2 Initials: 0
AutoNav: Enabled
Envelopeld Stamping: Enabled
Time Zone: (UTC-06:00) Central Time (US & Canada)
Record Tracking
Status: Original
8/4/2023 3:19:33 PM
Security Appliance Status: Connected
Storage Appliance Status: Connected
Signer Events
Tray Payne
TrayPayne@mylubbock.us
Mayor
City of Lubbock
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Roderick Swan
roderick.swan@hhs.texas.gov
Associate Commissioner
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
In Person Signer Events
Editor Delivery Events
Agent Delivery Events
Intermediary Delivery Events
Certified Delivery Events
Holder: Texas Health and Human Services
Commission
PCS_DocuSign@hhsc. state.tx. us
Pool: FedRamp
Pool: Texas Health and Human Services
Commission
Signature
ED—Sig-d by:
1�3r7V
lFE3z�laD
Signature Adoption: Pre -selected Style
Using IP Address: 208.84.91.41
DoeuSignM by:
E
O�F,19B A7 SWcUn,
E79F 19BTA718dAD
Signature Adoption: Pre -selected Style
Using IP Address: 72.179.41.247
Signature
Status
Status
Status
Status
Carbon Copy Events
Status
SA Mailbox
SUD.Contracts@hhs.texas.gov
COPIED
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
DocuSign
Status: Completed
Envelope Originator:
Texas Health and Human Services Commission
1100 W. 49th St.
Austin, TX 78756
PCS—DocuSign@hhsc.state.tx.us
IP Address: 168.60.145.83
Location: DocuSign
Location: DocuSign
Timestamp
Sent: 8/4/2023 3:40:30 PM
Resent: 8/24/2023 10:49:00 PM
Viewed: 8/25/2023 2:25:25 PM
Signed: 8/28/2023 8:53:46 AM
Sent: 8/28/2023 8:53:48 AM
Viewed: 8/28/2023 8:58:19 AM
Signed: 8/28/2023 8:58:55 AM
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Timestamp
Sent: 8/4/2023 3:40:30 PM
Viewed: 8/21/2023 9:00:18 PM
Carbon Copy Events Status Timestamp
Not Offered via DocuSign
Cristina Bunyard
cristina.bunyard@hhs.texas.gov
Contract Specialist IV
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
COPIED
Katherine Wells COPIED
kwells@mylubbock.us
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Megan Miller COPIED
mmiller@mylubbock.us
Security Level: Email, Account Authentication
(None)
Electronic Record and Signature Disclosure:
Not Offered via DocuSign
Sent: 8/4/2023 3:40:29 PM
Viewed: 8/28/2023 9:43:54 AM
Sent: 8/24/2023 10:48:53 PM
Viewed: 8/25/2023 6:11:01 AM
Sent: 8/24/2023 10:48:53 PM
Witness Events
Signature
Timestamp
Notary Events
Signature
Timestamp
Envelope Summary Events
Status
Timestamps
Envelope Sent
Hashed/Encrypted
8/4/2023 3:40:30 PM
Envelope Updated
Security Checked
8/24/2023 10:48:52 PM
Envelope Updated
Security Checked
8/24/2023 10:48:52 PM
Envelope Updated
Security Checked
8/24/2023 10:48:52 PM
Certified Delivered
Security Checked
8/28/2023 8:58:19 AM
Signing Complete
Security Checked
8/28/2023 8:58:55 AM
Completed
Security Checked
8/28/2023 8:58:55 AM
Payment Events
Status
Timestamps