HomeMy WebLinkAbout2012-407 Health - Orange Co Head Start & Early Head Start Services to Children enrolled Ot OCHS/EHS Agreement with OCEHS for Dental Services �i f
FY 2012-13
AGREEMENT BETWEEN
ORANGE COUNTY HEALTH DEPARTMENT
AND
CHAPEL HILL TRAINING AND OUTREACH, INC.,
FOR DENTAL SERVICES FOR ORANGE COUNTY HEAD START AND EARLY HEAD START
THIS AGREEMENT made and entered into on the 1't day of September, 2012 by and between
The Orange County Health Department hereinafter referred to as"OCHD"for its Dental Health Services
Division; and the Orange County Head Start/Early Head Start Program of the Chapel Hill Training and
Outreach Inc., hereinafter referred to as "OCHS/EHS".
WITNESSETH
WHEREAS, OCHS/EHS desires the services of a dentist(s)licensed by the State of North
Carolina with experience or training in children's dentistry, and
WHEREAS, the Health Coordinator of OCHS/EHS and the Director of Dental Health
Services, OCHD shall administer this program and,
WHEREAS, OCHD desires to contract with OCHS/EHS to provide a dentist(s)licensed by the
State of North Carolina to provide services and to serve as a consultant to OCHS/EHS;
NOW THEREFORE, in consideration of the premises and of the following mutual
promises, covenants and conditions, OCHD and OCHS/EHS agree as follows:
1. OCHD shall provide a dentist(s)licensed to practice in the State of North Carolina to be available
to OCHS/EHS to serve as a consultant, and to provide dental services to the children enrolled at
OCHS/EHS who do not have a dental home. A full examination is required within 90 days of
enrollment; that examination will be conducted at the OCHD Hillsborough dental services site.
2. OCHD will provide treatment services:
A) Examination
B)Needed extractions
C) Needed restoration including pulp therapy and stainless steel crowns
D)Prophylaxis and topical fluoride application where indicated
E)Provide follow-up documentation of dental exams and treatment on each child
F) Referral of children with severe need to UNC School of Dentistry for evaluation and
possible acceptance for treatment
3. OCHD will complete the CAP-H.S.S.-30 forms pertaining to dental health and return the forms
to OCHS/EHS to be made a part of the child's permanent Head Start record within one week of the
exam.
4. OCHD will file for Medicaid/other third party insurance plans for reimbursement when
necessary(OCHS/EHS is not a health provider, therefore cannot file).
5. OCHD will submit a bill to Angela Wilcox, Director, OCHS/EHS, in the amount of$1500 on an
annual basis by June 30, 2013. The dental services will include dental exams and follow-up services
needed for 10-15 Head Start children who do not have a dental home and are eligible for Medicaid. The
check should be made payable to Orange County Health Department and mailed to-.l ie-I=angstcn,
Financial &Administrative Operation Director, PO Box 8181, Hillsborough, NC. (7*yiS}� efOOSIle'r
6. OCHS/EHS agrees as follows:
a.Two weeks in advance, coordinate with OCHD to schedule appointments for children needing
S:\Managers Working Files\Contracts\Dental\FY 11-12 Head Start Dental Contract.doc
Agreement with 0CEH for Dental Services
FY 2012-13
services on the OCHO Dental C|inicaohadu|e/caendar.
b. Encourage parents to arrive to appointments on-time and require parents to inform
OCHSVEHS and OCHDif cancellation isnecessary,
cJo provide necessary parental permissions, information for the Eligibility Determination
forms, and the Medical and Dental Histories for each child prior to that child undergoing
treatment. C)CHSVEH8 will bring all signed forms prior to the day ofservice.
d.To provide CAP-H.S.S.-30 forms or OCHS/EHS form pertaining to dental health and will
make the completed form a port of the child's permanent OCH8/EHS record.
e. To obtain a copy of each child's Medicaid card or other dental insurance and bring a copy
tp the OCHOon the scheduled day ofservice.
7. In the event that enrollment in OCHSVEHS program ceases or is significantly reduced during the
term of this agreement, [3CHS/EH@ may terminate this agreement upon 3O days notice and (]CHOwill
return a pro rata share of the payment for services not provided (approximately$100 per enrolled child for
those children whose dental work has not been abarted).
8.. The parties agree that there shall be no unlawful discrimination bayed upon nooe, cm|or, enmeatry,
national origin, ne|igion, sex, age, disability orveteran status.
� Q. The parties agree to abide by HIPAA regulations in the sharing of protected health
10. The term of this initial Agreement is for a period of one year commencing on the 9th day of July,
2012 and terminating on the 8th day of July, 2013. This agreement shall be renewable by written
agreement signed by the official representatives of the parties. Either party may terminate this Agreement
after providing thirty(30)days notice.
11. The parties agree to the full and complete performance of the mutual covenants contained herein
and that this Agreement constitutes the sole,full and complete agreement by and between the parties;
and no amendments, changes, additions, deletions or modifications to or of this Agreement shall be valid
unless reduced to writing, signed by the parties and attached hereto.
12. This agreement shall be governed by the laws of the State of North Carolina.
S:\Managers Working Files\Contracts\Dental\FY 11-12 Head Start Dental Contract.doc
Agreement with OCEHS for Dental Services
FY 2012-13
FOR AND ON BEHALF OF
ORANGE COUNTY HEAD START/EARLY HEAD START
Angela Wilcox,qector Date
FOR AND ON BEHALF OF THE HEALTH DEPARTMENT
Colleen M. Bridger, Health Dire
, r Date
Orange County Health Department
FOR AND ON BEHALF OF THE COUNTY OF ORANGE
Frank Clifton, County Ma er Date
Approved as to rm and legal sufficiency
,,.kj�� 11
ArMette M. Wore, Staff Attorney Dke
ORANGE COUNTY FINANCE DIRECTOR:
"This instrument has been pre-audited in the
manner required by the Local Government
Budget and Fiscal Control Act."
/it Al- 2
Clarence Grier Date
Finance Director
S:\Managers Working Files\Contracts\Dental\FY 11-12 Head Start Dental Contract.doc