HomeMy WebLinkAbout2014-338 Housing - Steven Dah Edison for translation or interpretation services $2,000 SO
ORANGE COUNTY
COUNTYWIDE INTERPRETER CONTRACT
NORTH CAROLINA (15,000 OR LESS)
THIS AGREEMENT, made and entered into this 1st day of July, 2014, ("Effective Date") by and
between Orange County, North Carolina, a body politic and corporate organized under the laws of the State
of North Carolina, (the"County"),and Steven Dah Edison(the"Provider");
WITNESSETH:
For the purpose and subject to the following terms and conditions hereinafter set forth, the County
hereby contracts for the services of the Provider, and the Provider agrees to provide t'ae following
Interpretation Services (hereinafter referred to as "Services") to the County in accordance wits.the terms of
this Agreement,time being of the essence.
1. Contract. This Contract consists of this document and additional documents checked
below:
a. For Health Department:
i. ® Health Department Additional Terms and Conditions
ii. ® Business Associates Agreement
iii. ® Condition of Contract Statement
b. For Department of Social Services:
i. ❑ The General Terms and Conditions (Attachment A);
ii. ® The Scope of Work, description of services, and rate (Attachment B);
iii. ® Federal Certification Regarding Drug-Free Workplace (Attachment C);
iv. ® Conflict of Interest(Attachment D);
v. ®No Overdue Taxes (Attachment E);
vi. ❑ Outcomes and Reporting(Attachment N)
These documents constitute the entire agreement between the Parties and supersede all prior oral
or written statements or agreements.
2. Provider's Responsibilities:
a. The Provider shall be qualified to interpret between English and Karen with the client and
County staff.
b. Professional Conduct. The Provider shall adhere to the standards of professional conduct of
an interpreter while conducting the services to include the following:
i. The Provider shall relate to all County clients and staff in a re 3pectful and
professional manner.
ii. The Provider will interpret the information being shared between client/family and
staff as clearly as possible, without additional personal comments or biases on the
topic being discussed.
1
Revised May 2014
iii. The provider when providing interpretation services will interpret the i aformation as
clearly as possible without changing the meaning and the intent of the conversation.
iv. The Provider will interpret the information to the best of his/her ability.
c. Client Confidentiality.
L The Provider acknowledges that she/he may have access to information that is
confidential and provided by state and federal laws and agrees to comply with all
privacy policies, regulations, and laws as well as the Health Insurance Portability
and Accountability Act (HIPAA) of 1996 (P.L.104-191).
ii. The Provider agrees to protect confidential information (e.g., client name,
appointment type, telephone number, health information) that he/she may receive in
doing business with County. The Provider should ensure proper, saf.- storage and
protection of client information during use, and shredding/deletion of such
information when it is no longer necessary for business purposes.
iii. Breaches of client confidentiality will result in automatic termination of this
Agreement.
d. Scope of Services.
i. Procedures and Guidelines Upon Acceptance of an Interpretation Assignment:
1. The Provider agrees to give at least 24 hour notice if he/shc: is unable to
participate in a scheduled client contact.
2. The Provider will be expected to make confirmation phone calls to clients in
advance of an assigned appointment, when feasible, and when the Provider
is provided the information by County staff. The Provider Should notify
County staff as soon as possible if the client has told the Provider that he/she
will not be able to make the appointment and/or if he/,;he needs to
reschedule. These confirmation calls will not be paid for sepai-ately, but are
considered part of the service when the Provider accepts an assignment for
an appointment.
3. The Provider shall not have contact with County clients without County
staff being present, unless specifically asked by staff to call clients to
confirm or schedule appointments. It is not acceptable for the Provider to
give out his/her home telephone number or cell phone number for later
contact between the family and Provider.
3. County's Responsibilities. County will compensate Provider as provided in subsection 4 for
interpretation services at the rate prescribed. Per hour reimbursement will begin at the time the
Provider meets with County staff for the appointment and ends at the time the staff and
interpreter contact is completed. There will be a minimum of one (1) hour of service for an
appointment. There will be a minimum of one (1) hour of service for an appointment. County
will reimburse the Provider for one (1) hour of interpretation service in the event of a same day
cancelled appointment. That includes appointments for clients who do not show up for an
appointment, and for those who cancel an appointment with less than 24 hour notice:.
2
Revised May 2014
4. Payment for Services: The County agrees to pay at the rates specified for Services satisfactorily
performed in accord with this Agreement. The amount to be paid by the County shall not exceed
$2000 ($35/hour for Interpretation Services). Payment shall be made within thirty (30) days of
an invoice properly submitted to County. Should Provider fail to perform its duties under the
terms of this Agreement, County may,without fault or penalty, withhold any payment associated
with the work to be performed until such time as said work is completed. The procedures for
payment of services rendered shall be as follows:
a. The Provider. The Provider will complete and submit the County Invoice for Payment of
Interpretation Services form to County staff at the time the service is rendered. County staff
will verify the information, sign and forward the form for payment of services.
b. For interpretation services:
i. The Provider will record the start and finish time worked to the minute. After the
first hour of service,payment will be calculated and paid per minute.
ii. The Provider shall submit one invoice per client, unless there i,,, a block of
appointments without interruption. Without interruption means that there were no
cancelled appointments and no lunch hour included. This is appropriai:e for a group
of clients who are served for the same type of appointment, at the s,nne location.
For question, contact the departmental contact.
iii. In the event of a cancelled appointment, the Provider is required to stay until
relieved of duty by the individual in charge. County staff may require other
interpreter-related services in place of the scheduled appointment. As stated above,
the Provider may submit an invoice in the event of a broken appointment (with less
than 24 hour notice).
iv. If the Provider is assisting County staff with a large volume of phone calls outside of
a scheduled appointment time, the Provider should complete a Call Log to submit
along with an invoice describing the services performed. This type of service is paid
by the minute,without a one hour minute requirement for payment.
v. In the case of an unexpected closing or delayed opening(e.g., inclement weather) of
the County Offices when providing interpretation services, the Provider shall not be
paid for missed appointments. When in doubt,the Provider can call 73 2-8181 to see
if county offices are open or are on a delayed schedule. When possible, the Provider
is also asked to help call his/her scheduled clients to inform them of the delay or
closing.
5. Term.. The term of this Agreement shall be from July 1,2014 to June 30, 2015.
6. Errors and Omissions. Provider represents and agrees that Provider is qualified to perform and
fully capable of performing and providing the services required or necessary under this
Agreement in a fully competent, professional and timely manner to the satisfaction of the
County. Provider shall be responsible for all errors or omissions, in the performance of the
Agreement. Provider shall correct any and all errors, omissions, discrepancies, ambiguities,
mistakes or conflicts at no additional cost to the County.
7. Additional Terms and Condition. The County may have additional terms and condition that
shall be provided as attachment 1, and shall be attached and are hereby ineDrporated by
reference.
3
Revised May 2014
8. Precedence Among Contract Documents: In the event of a conflict between or among
the terms of the Contract Documents, the terms in the Contract Docum.-nt with the
highest relative precedence shall prevail. The order of precedence shall be the order of
documents as listed in Paragraph 1, above, with this contract document having the
highest precedence then the first listed document and the last-listed document having the
lowest precedence. If there are multiple Contract Amendments, the most recent
amendment shall have the highest precedence and the oldest amendment shall have the
lowest precedence.
9. Non—waiver: Failure by County at any time to require the performance by Provider of any of the
provisions hereof shall in no way waive or affect the County's right hereunder t3 enforce the
same,nor shall any waiver by the County of any breach be held to be a waiver of any succeeding
breach or a waiver of this Non-Waiver Clause.
10. Independent Contractor: The Provider shall operate as an independent Provider, ar._d the County
shall not be responsible for any of the Provider's acts or omissions. The Provider shall not be
treated as an employee with respect to the Services performed hereunder for federal or state tax,
unemployment or workers' compensation purposes. The Provider understands that neither
federal, nor state, nor shall payroll tax of any kind be withheld or paid by the County on behalf
of the Provider or the employees of the Provider.
11. Insurance: The Provider shall obtain, at its sole expense, all insurance needed to adequately
insure itself during the performance of these services.
12. Indemnity: The Provider agrees to defend, indemnify, and hold harmless Orange County from all
losses, liabilities, claims, demands, suits, costs, damages or expenses (including reasonable
attorney's fees) arising from bodily injury, including death, to any person or perso:-is or damage
to or destruction of any property caused in whole or in part by any negligent or intentional act or
omission on the part of the Provider.
13. Termination: This Agreement may be terminated at any time by mutual written agreement of the
parties or by the County upon written notice to the Provider.
14. Entire Agreement: The parties have read this Agreement and agree to be bound by all of its
terms, and farther agree that it constitutes the complete and exclusive statement of the
Agreement between the parties unless and until modified in writing and signed by the parties.
Modifications may be evidenced by telefacsimile signature.
15. Governing Law: Both parties agree that this Agreement shall be governed by the laws of the
State of North Carolina. Should either party initiate litigation to settle any dispute involving the
terms of this Agreement such litigation shall be initiated in the General Court of Ju,tice of North
Carolina seated in Orange County, North Carolina. Provider shall at all timos remain in
compliance with all applicable local, state, and federal laws, rules, and regulations including but
not limited to all anti-discrimination laws. Pursuant to the terms of North Carolina General
Statute 153A-449(b) no county may enter into a contract with a contractor unless the contractor
and the contractor's subcontractors comply with the requirements of Article 2 of Chapter 64 of
the North Carolina General Statutes. Where applicable, failure to maintain compliance with the
requirements of Article 2 of Chapter 64 of the General Statutes constitutes Provider's breach of
this Agreement. By executing this Agreement Provider affirms Provider is in compliance with
Article 2 of Chapter 64 of the North Carolina General Statutes.
4
Revised May 2014
16. Non Appropriation: Provider acknowledges that County is a governmental entity, and the
validity of this Agreement is based upon the availability of public funding under the authority of
its statutory mandate. In the event that public funds are unavailable and not appropriated for the
performance of County's obligations under this Agreement, then this Ag-eement shall
automatically expire without penalty to County immediately upon written notice to Provider of
the unavailability and non-appropriation of public funds.
IN WITNESS WHEREOF,Orange County and the Provider have signed this Agreement, effective
as of the day first written above.
ORANGE COUNTY PROVIDER: Steven D-ah Edison
�
B >
y: By:
Bonnie Hammersley ``
County Manager r Title: 64CA T
200 S. Cameron St. 1105 Hwy 54 Bypass,Al I-9
P.O. Box 8181 Chapel Hill,NC 27516
Hillsborough,NC 27278
This instrument lAs been approved as to technical content.
J es E.D i ,Jr
erim Director, Housing, ng and Community Development Department
This instrument has been pre-audited in the manner required by the Local Government Budget end Fiscal
� �ontrol Act. ��
444 aAA
tw (AC st Q cr(a4r oc��
Clarence G. Grier, Finance Director
This i t ent s ee approved as to form and legal sufficiency.
Anne le X4.Moore Staff Attorne
5
Revised May 2014
Orange County Health Department(hereinafter referred to as "OCHD")
Additional Terms and Conditions
These are additional terms and conditions to the Agreement between Orange County and the
(PROVIDER)to the Countywide Interpreter Translator Contract of$15,000 or less. The additional
terms and conditions shall supersede any terms in the original contract and are hereby incorporated
as follows:
Add to Section 2.b.
V. The Provider will follow the National Code of Ethics and Standards of
Practice outlined by the National Council on Interpreting in Health
Care which can be found at www.ncihc.org and is hereby incorporated
by reference.
vi. The Provider is required to sign the OCHD Conditions of Contract
Statement containing the confidentiality, Title X and public health
activities in emergency situations information which is hereby
incorporated by reference.
Add to Section 2.d.i.3 the following sentence:
The Provider should generally instruct clients to call the Health
Department front desk staff or the Spanish voicemail line; at 644-3350
(when language appropriate) to schedule an appointment or to inquire
about services.
Add Section 2.e.
e. Medical Documentation. The Provider is required to:
i. Provide proof of immunity to varicella, measles, mumps and rubella prior to
inception of contract work. Proof of immunity must be one of the
following: medical records diagnosing the disease, laboratory records
confirming the disease, laboratory records documenting po 3itive disease
titers, or medical records documenting receipt of 2 doses of --ach vaccine.
(Exception: If the Provider has documentation of only one dose of vaccine,
the Provider must provide documentation of a second dose within 60 days of
the first day of contract work.) The Provider is responsible for covering all
costs associated with acquiring any necessary titers, medical diagnosis or
laboratory confirmation of disease or vaccinations.
ii.Provide proof of a TB screening and provide those results to CCHD prior to
beginning contract work. The Provider is responsible for the costs associated
with acquiring such screening. The screening can be one of the following:
1. Receipt of a TB skin test (TST) if the Provider has no history of TB
infection/disease or of a positive TST(Note: If the Provider has not
had an additional TST within the previous 12 months, a second TST
6
Revised May 2014
will be required one week after the first to establis.1 an accurate
baseline.)
2. Completion of a TB Screening Form by a medical provider if the
Provider has a history of TB disease or of having a positive TST.
ii. Provide proof of Tdap vaccine prior to beginning contract work.
Replace Section 3 with the following paragraph:
3. County's Responsibilities. County will compensate Provider as provided in subsection 4
for interpretation and translation services at the rate prescribed. Per hour reimbursement
will begin at the time the Provider meets with County staff for the appointment and ends
at the time the staff and interpreter contact is completed. There will be z minimum of
one (1) hour of service for an appointment. OCHD will reimburse the Provider for one
(1)hour of interpretation service in the event of a same day cancelled appointment. That
includes appointments for clients who do not show up for an appointment, and for those
who cancel an appointment with less than 24 hour notice. Exception: "Family"Refugee
Health Assessment (communicable disease and/or physical exam) appointments with 3
or more family members will only be reimbursed for a total of two (2) hoLrs in the case
of same day cancelled appointments. OCHD will not reimburse the Provider if an
appointment is cancelled with more than 24 hour notice.
Add to Section 4.b.iii the following sentence:
iii. In the event of a cancelled appointment,the Provider is require d to stay until
relieved of duty by the nurse supervisor or the individual in charge of
clinical operations. OCHD staff may require other interpreter-related
services in place of the scheduled appointment. As stated above, the
Provider may submit an invoice in the event of a broken appo intment (with
less than 24 hour notice).
7
Revised May 2014
BUSINESS ASSOCIATE AGREEMENT
This Business Associate Agreement ("Agreement") is made effective the First day o:.'July, 2014,
by and between Orange County Government through its Orange County Health Departmert ("Covered
Entity"), and Steven Dah Edison, ("Business Associate"). Covered Entity and Business Associate may be
referred herein individually as a"Party" or collectively as the"Parties". This Agreement supersedes any
previously executed Business Associate Agreement between the Parties.
WITNESSETH:
WHEREAS, Sections 261 through 264 of the federal Health Insurance Portability and
Accountability Act of 1996 ("HIPAA'), Public Law 104-191, as modified by the Health Information
Technology for Economic and Clinical Health Act ("HITECH"), Public Law 111-5, known as "the
Administrative Simplification provisions," direct the Department of Health and Human Services to
develop standards to protect the security, confidentiality and integrity of health information; a ad
WHEREAS, pursuant to the Administrative Simplification provisions, the Secretary of Health and
Human Services ("Secretary") has issued regulations modifying the Privacy, Security, Breach
Notification, and Enforcement Rules at 45 CFR Parts 160 and 164, as the same may be amended from
time to time(the"HIPAA Security and Privacy Rule"); and
WHEREAS, the Parties wish to enter into or have entered into an arrangement whereby Business
Associate will provide certain services to Covered Entity, and, pursuant to such arrangements, Business
Associate may be considered a"Business Associate"of Covered Entity as defined in the HIPAA Security
and Privacy Rule (the agreement evidencing such arrangement is detailed below and hereinafter referred
to as the"Service Agreement(s)"); and
WHEREAS, Business Associate may have access to Protected Health Information (as defined below) in
fulfilling its responsibilities under such arrangement;
THEREFORE, in consideration of the Parties' continuing obligations under the Service Agreement,
compliance with the HIPAA Security and Privacy Rule, and other good and valuable consideration, the
receipt and sufficiency of which is hereby acknowledged, the Parties agree to the provisions of this
Agreement in order to address the requirements of the HIPAA Security and Privacy Rule and to protect
the interests of both Parties.
I. DEFINITIONS
(a) Service Agreement. Agreement(s) for services affected by this HIPAA Business
Associate Agreement, which this Business Associate Agreement shall be attached to, and is (are) hereby
incorporated by reference, and which shall be taken and considered as a part of this document the same as
if fully set out herein:
COUNTYWIDE INTERPRETER CONTRACT($15,000 OR LESS)
(b) Catch-all Provision. Except as otherwise defined herein, any and all capitalized terms in
this Agreement shall have the definitions set forth in the HIPAA Security and Privacy Rule, 45 CFR Parts
160 and 164, subparts A and E. In the event of an inconsistency between the provisions of this Agreement
and mandatory provisions of the HIPAA Security and Privacy Rule, as amended,the HIPAA Security and
Privacy Rule shall control. Where provisions of this Agreement are different than those mar..dated in the
HIPAA Security and Privacy Rule, but are nonetheless permitted by the HIPAA Security and Privacy
Rule, the provisions of this Agreement shall control.
I
October 2013
(c) Electronic Protected Health Information. Protected Health Information that i; transmitted
by or maintained in Electronic Media(as defined in the HIPAA Security and Privacy Rule).
(d) Protected Health Information. "Protected Health Information" shall hav,- the same
meaning as the term in 45 CFR § 160.103, limited to the information created or received 3y Business
Associate from or on behalf of Covered Entity and includes without limitation "Electronic Protected
Health Information." Business Associate acknowledges and agrees that all Protected Health Information
that is created or received by Covered Entity and disclosed or made available in any form, including paper
record, oral communication, audio recording, and electronic display by Covered Entity or its operating
units to Business Associate or is created or received by Business Associate on Covered Entity's behalf
shall be subject to this Agreement.
(e) Required by Law. "Required by Law" shall have the same meaning as the term in 45
CFR§ 164.103.
II. OBLIGATIONS AND ACTIVITIES OF BUSINESS ASSOCIATE
(a) Use and Disclosure. Business Associate agrees to fully comply with the requirements
under the HIPPA Security and Privacy Rule applicable to Business Associates and not to use or disclose
Protected Health Information other than as permitted or required by this Agreement, the Service
Agreement or as Required by Law. To the extent Business Associate carries out obligations of Covered
Entity under the HIPAA Security and Privacy Rule, Business Associate shall comply with th-.applicable
provisions of the HIPAA Security and Privacy Rule as if such use or disclosure were made by Covered
Entity. Business Associate agrees to comply with Covered Entity's policies regarding the minimum
necessary use or disclosure of Protected Health Information.
(b) Appropriate Safeguards. Business Associate agrees to use appropriate safeguards to
prevent use or disclosure of Protected Health Information other than as provided for by This Service
Agreement(s), this Agreement or as Required by Law. This includes the implementation physical,
technical and administrative safeguards to prevent use or disclosure of Protected Health Information other
than as permitted in this Agreement or Required by Law and reasonably and appropriately protect the
confidentiality, integrity, and availability of any Electronic Protected Health Information that it creates,
receives, maintains, or transmits on behalf of Covered Entity as required by the HIPAA S ecurity and
Privacy Rule. The Business Associate shall maintain appropriate documentation of its compliance with
the HIPPA Security and Privacy Rule, including, but not limited to, its policies, procedures, records of
training and sanctions of members in its workforce.
(c) Assurances. Business Associate agrees to provide Covered Entity with written
assurances that any Protected Health Information placed on any type of mobile media, including, but by
no means limited to, lap top computers, Ipads and mobile phones, is encrypted in accordance with
guidance issued by the Secretary.
(d) Agents and Subcontractors. Business Associate shall require any agents, in-.luding any
subcontractors, to whom it provides Protected Health Information from Covered Entity that is created,
received, maintained or transmitted on behalf of Business Associate to agree by written contract with
Business Associate to the same (or greater) restrictions, conditions and requirements that apply to
Business Associate with respect to such information, and to agree to implement reasonable and
appropriate safeguards to protect any of such information that is Electronic Protected Health Information.
In addition, Business Associate agrees to take reasonable steps to ensure that its employees' actions or
omissions do not cause Business Associate to breach the terms of this Agreement.
(e) Mitigation of Breach. Business Associate agrees to mitigate, to the extent practicable,
any harmful effect that is known to Business Associate of a use or disclosure of Protested Health
2
October 2013
Information by Business Associate in violation of the requirements of this Agreement, a, well as to
provide complete cooperation to Covered Entity should Covered Entity elect to review or investigate such
noncompliance or Security Incident. Business Associate shall cooperate in Covered Entity's breach
analysis and/or risk assessment, if requested. Furthermore, Business Associate shall cooperate with
Covered Entity in the event that Covered Entity determines that any third parties must be notified of a
Breach, provided that Business Associate shall not provide any such notification except at the direction of
Covered Entity.
(f) Breach Reporting. Business Associate shall report in writing to Covered Entity's Privacy
Officer (see Exhibit A), any use or disclosure of Protected Health Information that is not in compliance
with the terms of this Agreement, as well as any Security Incident and any actual or suspected Breach, of
which it becomes aware, without unreasonable delay, and in no event later than forty-eight (18) hours of
such discovery. For purposes of this Agreement, "Security Incident" means the attempted cr successful
unauthorized access, use, disclosure, modification, or destruction of information or interference with
system operations in an information system. Such notification shall contain the elements required by 45
C.F.R. § 164.410.
(g) Compliance. To the extent applicable, Business Associate will comply with (i) Covered
Entity's Notice of Privacy Practices; (ii) any limitations to which Covered Entity has agreed in regard to
an Individual's permission to use or disclose his or her Protected Health Information; aad (iii) any
restrictions to the use or disclosure of Protected Health Information to which Covered Entity has agreed
or is required to agree.
(h) Government Access. Business Associate will make its internal practices, books and
records available to the Secretary of the Department of Health and Human Services for purposes of
determining compliance with the terms of the HIPAA Security and Privacy Rule, and, at the request of
the Secretary, will comply with any investigations and compliance reviews, permit access to information,
and cooperate with any complaints, as Required by Law. Without unreasonable delay and, vi any event,
no more than 48 hours of receipt of the request or notification, Business Associate will notify Covered
Entity in writing of any request by any governmental entity, or its designee, to review Business
assessment of any kind.
(i) Electronic Transactions. If Business Associate conducts any Standard Transactions for or
on behalf of Covered Entity, Business Associate shall comply with the requirements under th.-Electronic
Transaction Rule.
0) Audit. Business Associate shall permit Covered Entity, in its discretion, to conduct an
audit of Business Associate's compliance with this Agreement, HIPAA, and HITECH. Sucli audit may
consist of an onsite visit, a series of inquiries that require written responses, or both. Business Associate
shall promptly and completely respond to Covered Entity's requests for information in support of the
audit, which shall not be conducted more than once annually except in cases of an actual or reasonably
suspected Security Incident or reasonably suspected noncompliance with this Agreement, HIPAA or
HITECH. Each Party shall bear its own costs associated with the audit.
(k) Identity Theft. Business Associate shall implement Identity Theft Monitorng Policies
and Procedures to protect any patient information that may be breached by the Business Associate to the
extent applicable under the Federal Trade Commission's Red Flag Rules.
(1) HITECH Compliance. Business Associate shall:
A. Not receive, directly or indirectly, any impermissible remuneration in exchange
for Protected Health Information or Electronic Protected Health Information,
except as permitted by HITECH § 13405(d) or the HIPPA Regulations;
3
October 2013
B. Comply with the marketing and other restrictions applicable .o Business
Associates contained in HITECH § 13406 and the HIPPA Regulations;
C. To the extent required under HITECH § 13404, fully comply with tl.e applicable
requirements of 45 CFR 164.502(e)(2) for each use and disclosure of Protected
Health Information;
D. To the extent required under HITECH § 13401, fully comply with 45 CFR §§
164.308, 164.310, 164.312, and 164.316;
E. To the extent required under HITECH §§13401 and 13404, comply with the
additional privacy and security requirements that apply to Covered Entities in the
same manner and to the same extent as Covered Entity is required to do so; and
F. To the extent required under the HIPPA Regulations, comply with the privacy
and security requirements that apply to Business Associates.
(m) State Privacy Laws. Business Associate shall understand and comply with state privacy
laws to the extent that such privacy laws are not preempted by HIPPA or HITECH.
III. PERMITTED USES AND DISCLOSURES BY BUSINESS ASSOCIATE
(a) Use of Protected Health Information on Behalf of Covered Entity. Except as otherwise
limited in this Agreement, Business Associate may .use or disclose Protected Health Information to
perform functions, activities or services for, or on behalf of, Covered Entity described in the Service
Agreement, provided that such use or disclosure would not violate the HIPPA Security and Frivacy Rule
if it were made by Covered Entity or would not violate the Covered Entities minimum necessary policies.
(b) Other Uses of Protected Health Information. Except as otherwise limited in this
Agreement, Business Associate may use Protected Health Information within its workforce fcr the proper
management and administration of Business Associate not to include Marketing or Commercial Use and
to carry out the legal responsibilities of Business Associate; and
(c) Third Party Confidentiality. Except as otherwise limited in this Agreement, Business
Associate may disclose Protected Health Information for the proper management and administration of
Business Associate or to carry out the legal responsibilities of Business Associate, provided that if
Business Associate discloses any Protected Health Information to a third party for such purpose, the
Business Associate shall enter into a written agreement with such third party requiring the following:
A. Disclosure only as Required by Law; or
B. Business Associate obtains reasonable assurances from the person to whom the
information is disclosed that the information will remain confidential and will be used or
further disclosed only as Required by Law or for the purpose for which it was disclosed
to the person, and the person notifies Business Associate of any instances of which it is
aware in which the confidentiality, integrity, and or availability of the Protected Health
Information has been breached immediately upon becoming aware.
(d) Business Associate may provide data aggregation services relating to the health care
operations of Covered Entity pursuant to any agreements between the Parties evidencing their business
relationship as permitted by 45 CFR§ 164.504(e)(2)(i)(B).
(e) Other Uses Strictly Limited. Nothing in this Agreement shall permit tl.e Business
Associate to share Protected Health Information with Business Associate's affiliates or contractors except
4
October 2013
for the purposes of the Service Agreement(s) between the Covered Entity and Business Associate(s)
identified in Section I(a) of this Agreement.
(f) Covered Entity Authorization for Additional Uses. Any use of Protected Health
Information by Business Associate, its affiliate or Contractor, other than those purposes of this
Agreement, shall require express written authorization by the Covered Entity, and a Business Associate
Agreement or amendment as necessary. Activities which are prohibited include, but are nct limited to,
Marketing, as defined by 45 CFR § 164.503 or the sharing for Commercial Use or any purpose construed
by Covered Entity as Marketing or Commercial Use, even if such sharing would be permitted by federal
or state laws.
(g) Business Associate may de-identify Protected Health Information only at the specific
direction of and only for the use of Covered Entity. Business Associate may not sell Protected Health
Information except at the direction of Covered Entity and in compliance with the requirerents of the
HIPAA Security and Privacy Rule.
IV. AVAILABILITY OF PHI
(a) Access to Protected Health Information. Business Associate agrees, in the event the
Business Associate maintains protected health information in a Designated Record Set, to make available,
within ten (10) days of a request by Covered Entity in a time and manner designated by Covered Entity,
Protected Health Information in a Designated Record Set, to Covered Entity or as directed by Covered
Entity, to an individual in order to meet the requirements of 45 CFR § 164.524 of the HIPAA Security
and Privacy Rule.
(b) Amendments to Protected Health Information. In the event that the Business Associate
maintains Protected Health Information in a Designated Record Set, Business Associate agr4;es to make
any amendment(s) to Protected Health Information in a designated record set that the Covered Entity
directs or agrees to pursuant to the HIPAA Security and Privacy Rule at the request of Covered Entity of
an individual,within ten(10)days of receipt of a request from Covered Entity and in the time and manner
designated by Covered Entity.
(c) Accounting of Disclosures. Business Associate agrees to maintain and make available
the information required to provide an accounting of disclosures, as required by 45 CFR§ 164.528 of the
HIPAA Security and Privacy Rule. Business Associate will comply with Covered Ent'.ty's policy
regarding accounting of disclosures.
(d) Document Disclosures. In the event an Individual makes a request under this Section of
the Agreement directly to Business Associate, Business Associate will notify Covered Entity of such
request within three (3) business days and shall cooperate with, and act only at the direction of Covered
Entity in responding to such request.
V. OBLIGATIONS OF COVERED ENTITY
(a) Notice of Privacy Practices. Covered Entity shall provide Business Associate with the
notice of privacy practice that Covered Entity produces in accordance with 45 CFR § 164.5X, as well as
any changes to that notice.
(b) Notice of Changes in Individual's Access or Protected Health Information. Covered
Entity shall provide Business Associate with any changes in, or revocation of, permission by an
Individual to use or disclose Protected Health Information, is such changes affect Business Associate's
permitted or required uses.
5
October2013
(c) Notice of Restriction in Individual's Access to Protected Health Information. Covered
Entity shall notify Business Associate of any restrictions to the use or disclosure of Prot,-cted Health
Information that Covered Entity has agreed in accordance with 45 CFR § 164.522 to the ext-.nt that such
restriction may affect Business Associate's use of Protected Health Information.
VI. PERMISSABLE REQUESTS BY COVERED ENTITY
Requests Permissible Under HIPAA. Covered Entity shall not request Business Associate to use
or disclose Protected Health Information in any manner that would not be permissible under the Privacy
or Security Rule.
VII. TERMINATION
(a) Term. This Agreement shall be effective as of the date first set forth above and shall
terminate upon the earlier of (i) the termination of all agreements between the parties, and (ii) the
termination by Covered Entity for cause as provided herein.
(b) Termination for Cause. Notwithstanding anything in this Agreement to the contrary,
Covered Entity shall have the right to terminate this Agreement and the Service Agreement immediately
if Covered Entity determines that Business Associate has or will violated any material germ of this
Agreement. Upon Covered Entity's knowledge of a material breach by Business Associate, Covered
Entity shall provide an opportunity for Business Associate to cure the breach or end the violation.
Covered Entity may terminate this Agreement if Business Associate does not cure the breach or end the
violation within the time period specified by Covered Entity. If termination, cure or end of the violation
is not feasible,Covered Entity may report the violation to the Secretary.
(c) Obligation of Business Associate Upon Termination. At termination of this Agreement,
the Service Agreement (or any similar documentation of the business relationship of the Parties), or upon
request of Covered Entity,whichever occurs first,Business Associate, shall:
A. if feasible,return(in a manner or process approved by the Covered Entity)or destroy
all Protected Health Information, regardless of form, including but not limited to
paper or electronic format, received from Covered Entity, or created, maintained or
received by Business Associate on behalf of Covered Entity. BusineEs Associate
shall retain no copies of the Protected Health Information. This provision shall also
apply to Protected Health Information and other confidential information in the
possession of sub-contractors or agents of Business Associate,
B. If such return or destruction is not feasible, Business Associate shall (i) retain only
that Protected Health Information necessary for Business Associate to continue its
proper management and administration or to carry out its legal respon&bilities; (ii)
return or destroy the remaining Protected Health Information that the Business
Associate still maintains in any form; (iii) extend the protections of this Agreement to
the retained Protected Health Information; (iv) limit further uses and di3closures to
those purposes that make the return or destruction of the Protected Health
Information not feasible; and (v) return or destroy the retained Protested Health
Information when it is no longer needed by Business Associate.
(d) Survival. This paragraph shall survive the termination of this Agreement and shall apply
to Protected Health Information created, maintained, or received by Business Associate and any of its
subcontractors.
V1111. MISCELLANEOUS
6
October 2013
(a) Indemnification. Business Associate agrees to indemnify, defend, and hold harmless
Covered Entity, its officers, agents, contractors and agents, against, and in respect of, any arLd all claims,
losses, expenses, costs, damages, obligations, penalties, and liabilities which Covered Entity may incur
by reason of Business Associate's breach of or failure to perform any its obligations pur3uant to this
Agreement, including but not limited to any injury or damages arising from any noncomplia-ice with this
Agreement or any Security Incident attributable to the negligence of Business Associate, including
failure to execute the terms of this Agreement. Further,Business Associate agrees to indemnify, defend,
and hold harmless Covered Entity, its officers, employees, contractors and agents, against all costs and
expenses, including but not limited to, reasonable legal expenses, which are incurred by or on behalf of
Business Associate in connection with the defense of such claims.
(b) Disclaimer. Covered Entity makes no warranty or representation that compliance by
Business Associate with this Agreement,HIPAA, HITECH, or the HIPAA Regulations will be adequate
or satisfactory for Business Associate's own purposes. Business Associate is solely responsible for all
decisions made by Business Associate regarding the safeguarding of Protected Health Information.
(c) Assistance in Litigation or Administrative Proceedings. Business Associate shall make
itself, and any subcontractors, employees, affiliates or agents assisting Business Associate in the
performance of its obligations under this Agreement, available to Covered Entity, at no cosy to Covered
Entity, to testify as witnesses, or otherwise, in the event of litigation or administrative procef;dings being
commenced against Covered Entity, its directors, officers or employees based upon a claimed violation
of HIPAA, HITECH, the HIPAA Regulations, or other laws relating to security and privacy, except
where Business Associate or its subcontractor, employee or agent is named adverse party.
(d) Survival. The obligations of Business Associate under this Agreement shall survive the
expiration, termination, or cancellation of this Agreement, the Service Agreement and/or the business
relationship of the parties, and shall continue to bind Business Associate, its agents, employees,
contractors, successors, and assigns as set forth herein.
(e) Ownership of Information. Covered Entity holds all right, title, and interest in and to the
Protected Health Information and Business Associate does not hold and will not acquire by virtue of this
Agreement or by virtue of providing goods or services to Covered Entity, any right, title, or interest in or
to the PHI or any portion thereof.
(f) Right to Injunctive Relief. Business Associate expressly acknowledges and agrees that
the breach, or threatened breach,by it of any provision of this Agreement may cause Covered Entity to be
irreparably harmed and that Covered Entity may not have an adequate remedy at law. Therefore,Business
Associate agrees that upon such breach, or threatened breach, Covered Entity will be entitled to seek
injunctive relief to prevent Business Associate from commencing or continuing any action constituting
such breach without having to post a bond or other security and without having to prove the inadequacy
of any other available remedies. Nothing in this paragraph will be deemed to limit or abrid€;e any other
remedy available to Covered Entity at law or in equity. Except as expressly stated herein or in the HIPAA
Security and Privacy Rule, the parties to this Agreement do not intend to create any rights in any third
parties.
(g) Amendment. The Parties agree to take such action as is necessary to amend this
Agreement from time to time as is necessary for Covered Entity to comply with the requirements of the
HIPSS Regulations. In addition, this Agreement may be amended or modified by the Parties only in
writing.
(h) Assignment. No Party may assign its respective rights and obligations under this
Agreement without the prior written consent of the other Party.
7
October 2013
(i) Independent Contractor. None of the provisions of this Agreement are intended to create,
nor will they be deemed to create any relationship between the Parties other than that of independent
parties contracting with each other solely for the purposes of effecting the provisions of this: Agreement
and any other agreements between the Parties evidencing their business relationship. This Agreement
will be governed by the laws of the State of North Carolina. No change, waiver or diSCILarge of any
liability or obligation hereunder on any one or more occasions shall be deemed a waiver of;)erformance
of any continuing or other obligation, or shall prohibit enforcement of any obligation, on any other
occasion.
0) Regulatory References. A reference in this Agreement to a section in HIPAA, HITECH
or the HIPAA Regulations means the section as it currently is in effect or as amended.
(k) Interpretation. Any ambiguity in this Agreement shall be resolved in favor cf a meaning
that permits Covered Entity to comply with the HIPAA Regulations. The parties agree that, in the event
that any documentation of the arrangement pursuant to which Business Associate provides services to
Covered Entity contains provisions relating to the use or disclosure of Protected Health Information that
are more restrictive than the provisions of this Agreement, the more restrictive provisions will control.
The provisions of this Agreement are intended to establish the minimum requirements regarding Business
Associate's use and disclosure of Protected Health Information.
(1) Severability. In the event any part or parts of this Agreement are held to be
unenforceable, the remainder of this Agreement will continue in effect. In addition, in the event a party
believes in good faith that any provision of this Agreement fails to comply with the hen-current
requirements of the HIPAA Security and Privacy Rule, such party shall notify the other party in writing.
For a period of up to (30) thirty days, the parties shall address in good faith such concern and amend the
terms of this Agreement, if necessary to bring it into compliance. If, after such thirty-day period, a party
believes in good faith that the Agreement fails to comply with the HIPAA Security and Privacy Rule,
then either party has the right to terminate upon written notice to the other party.
(m) Notices and Communications. All instructions, notices, consents, demands, or other
communications required or contemplated by this Agreement shall be in writing and shall be delivered to
the Parry at the address below:
For Covered Entity: For Business Associate
Orange County Housing,Human Rights
&Community Development Steven Dah Ldison
ATTN:Marlyn Valeiko 1105 Hwy 54 Bypass Apt I-9
300 W.Tryon Street Chapel Hill,NC 27`16
Hillsborough NC, 27278
(n) Strict compliance. No failure by any Party to insist upon strict compliance with any
terms or provisions of this Agreement, to exercise any option,to enforce any right, or to seek any remedy
upon any default of any other Party shall affect, or constitute a waiver of, any Party's right to insist upon
such strict compliance, exercise that option, enforce that right, or seek that remedy with respect to that
default or any prior, or contemporaneous, or subsequent default. No custom or practice of the Parties at
variance with any provisions of this Agreement shall affect, or constitute a waiver of, any Party's right to
demand strict compliance with all provisions of this Agreement.
(o) Governing Law. This Agreement shall be governed and construed in accordance with the
laws of the State of North Carolina except to the extent that North Carolina laws have been pre-empted by
HIPAA and without giving effect to principals of conflicts of law. Jurisdiction shall be Orange County,
North Carolina, for purposes of litigation resulting from disagreements of the Parties for purposes of this
Agreement and the Service Agreement(s).
8
October 2013
(p) E-Verify. Employers and their subcontractors with 25 or more employees E s defined in
Article 2 of Chapter 64 of the NC General Statutes must comply with E-Verify requirements to contract
with governmental units. E-Verify is a Federal program operated by the United States Department of
Homeland Security and other federal agencies, or any successor or equivalent program used to verify the
work authorization of newly hired employees pursuant to federal law. Where applicable, failure to
maintain compliance with the requirements of Article 2 of Chapter 64 of the North Carolina General
Statutes shall constitute breach of this Agreement. If applicable, by executing this Agreement, Business
Associate affirms that they are in compliance with Article 3 of Chapter 64 if the North Carolina General
Statutes.
IN WITNESS WHEREOF, the Parties have executed this Agreement as of the day and year written
above.
COVERED ENTITY: BUSINESS ASSOCIATE:
By: / By:
Title: Title: keyckil\
9
October 2013
EXHIBIT A
COVERED ENTITY PRIVACY OFFICER CONTACT INFORMATION
To report to Covered Entity any use or disclosure of Protected Health Information not in compliance with
the terms of this Agreement that might be considered a privacy breach,Business Associate should contact
the Privacy Officer at the applicable entity.To report to Covered Entity any Security Incident(as defined
in the Agreement),Business Associate should contact Carla Julian(919)245-2434,or the Se�mrity
Officer at The Orange County Health Department.
10
October 2013
ORANGE COUNTY HEALTH DEPARTMENT
Contracted Interpreters
Conditions of Contract Statement
Confidentiality
As a Contract Interpreter for Orange County Health Department(OCHD), I acknowledge that I may have
access to information that is confidential as mandated by state and federal law, HIPAA regulation and/or
Orange County policy. I recognize my legal obligation as a Contractor to maintain the confidentiality of
information about former and current recipients of OCHD services.
I understand that release of information determined to be confidential by law to unauthorized persons may
result in criminal prosecution. I further understand that the failure to maintain legally required confidentiality
of information constitutes"misconduct"within the meaning of the Orange County Personnel Ordinance and
may lead to disciplinary action, including termination of contract.
If a question arises regarding whether a release of information may be public record vs. confidential client
information, I will seek assistance from an OCHD Clinic Manager.
Title X Information Requirement
OCHD provides services solely on a voluntary basis. A client's acceptance of service is not e.prerequisite to
eligibility or receipt of a non-Title X service(Family Planning).
As an OCHD Contract Interpreter, you may be subject to prosecution under Federal law if yo coerce or
endeavor to coerce any person to undergo an abortion or a sterilization procedure.
As an Interpreter, your responsibility is to convey the message from the provider to the client to the best of
your ability, without prejudice or personal bias. If you are present when an OCHD employee attempts to
coerce a person to undergo an abortion or a sterilization procedure, discontinue interpreting, and report this to
the Clinic Manager.
Public Health Activities in Emergency Situations
In order to fulfill the responsibilities of the department in emergency situations or in training, and due to our
limited number of bilingual staff, you may be asked to work at emergency shelters or other lo,,-ations
designated by the Health Director or emergency operations. You may also be asked to participate in
emergency drills and exercises. As a Contractor, you do have the right to decline any of these special
requests.
I certify that I have read and understand the conditions stated above. I have had an opportun-Ay to discuss the
conditions and requirements of my contract with a designated agency representative.
Contractor Name: 4"Q, V-\ Date: 2
Contractor Signature: Date: C�
OCHD Representative: Date:
-�. --
\J
ATTACHMENT B
SCOPE OF WORK
Orange County Department of Social Services
Federal Tax Id. or SSN—moomm
Contract#
A. CONTRACTOR INFORMATION
1. Contractor Agency Name:
2. If different from Contract Administrator Information in General Contract:
Address
Telephone Number: Fax Number: Email:
3. Name of Program(s): Interpreter Services
4. Status: ( ) Public ( ) Private, Not for Profit (X) Private, For Profit
5. Contractor's Financial Reporting Year July 1, 2014 through June 30, 2015
B. Explanation of Services to be provided and to whom (include SIS Service Code):
C. Rate per unit of Service(define the unit):
1. If Standard Fixed Rate, Maximum Allowable, (See Rates for Services Chart)
2. Negotiated County Rate.
$35.00/hour - Interpretation
D. Number of units to be provided:
E. Details of Billing process and Time Frames; The County will reimburse the Co:itractor
for services described in this contract up to the budgetary limits of the contract allotment.
The County will reimburse the Contractor at a rate of$35.00/hour for approved services
provided and travel at the county rate. For reimbursement, the Contractor must submit the
Orange County Department of Social Services Invoice for Payment of InterpretiU
Services form to the County staff at the time services are rendered. County staff will
verify the information, sign the form, and forward the form to the designated Count
Administrator. The County will reimburse the Contractor monthly upon receipt o.'a
complete and correctly filed report.
Contract-Scope of Work(06/04) Page lof 2
Per hour reimbursement will beg_in at the time the Contractor meets with County staff for
the appointment and ends when the QqRn�t staff and Contractor contact is completed.
There will be a minimum of 1 hour of service for an appointment. Mileage
reimbursement will be for round trip from the Contractor's home or work site to the
prearranged appointment site
F. Area to be served/Delivery site(s): —Orange County
(Signature of County Aulfi6rized Person) (Signature of Contractor)
W�e', Ae C //�——
(Date Sufimitte(6 (Date Submitted)
Contract-Scope of Work(06/04) Pa 3,e 2of 2
ATTACHMENT C
CERTIFICATION REGARDING DRUG-FREE WORKPLACE REQUIREMENTS
Orange County Department of Social Services
I. By execution of this Agreement the Contractor certifies that it will provide a drug-flee
workplace by:
A. Publishing a statement notifying employees that the unlawful manufacture, distribution,
dispensing, possession or use of a controlled substance is prohibited in the Contractor's
workplace and specifying the actions that will be taken against employees for violation of
such prohibition;
B. Establishing a drug-free awareness program to inform employees about:
(1) The dangers of drug abuse in the workplace;
(2) The Contractor's policy of maintaining a drug-free workplace;
(3) Any available drug counseling, rehabilitation, and employee assistance programs; and
(4) The penalties that may be imposed upon employees for drug abuse violatior.s
occurring in the workplace;
C. Making it a requirement that each employee be engaged in the performance of the
agreement be given a copy of the statement required by paragraph(A);
D. Notifying the employee in the statement required by paragraph(A)that, as a condition of
employment under the agreement, the employee will:
(1)Abide by the terms of the statement; and
(2)Notify the employer of any criminal drug statute conviction for a violation occurring
in the workplace no later than five days after such conviction;
E. Notifying the County within ten days after receiving notice under subparagraph(D)(2)
from an employee or otherwise receiving actual notice of such conviction;
F. Taking one of the following actions, within 30 days of receiving notice under
subparagraph (D)(2), with respect to any employee who is so convicted:
(1) Taking appropriate personnel action against such an employee,up to and including
termination; or
(2) Requiring such employee to participate satisfactorily in a drug abuse assistance or
rehabilitation program approved for such purposes by a Federal, State, or lo,-,al health,
law enforcement, or other appropriate agency; and
Making a good faith effort to continue to maintain a drug-free workplace through implementation
of paragraphs (A), (B), (C), (D), (E), and (F).
Federal Certification-Drug-Free Workplace(06/04) Page 1 of 2
I1. The site(s) for the performance of work done in connection with the specific agreement are
listed below:
1. 113 Mayo Street
(Street address)
Hillsborough, Orange,NC, 27278
(City, county, state,zip code)
2. 2501 Homestead Road--
(Street address)
Chapel Hill, Orange,NC, 27516
(City, county, state, zip code)
Contractor will inform the County of any additional sites for performance of work under this
agreement.
False certification or violation of the certification shall be grounds for suspension of payment,
suspension or termination of grants, or government-wide Federal suspension or debarment
(Section 4 CFR Part 85, Section 85.615 and 86.620).
Signature Title
6 �� � i �
Agency/Organization Date
(Certification signature should be same as Contract signature.)
Federal Certification-Drug-Free Workplace(06/04) Page 2 oj.'2
ATTACHMENT D
CONFLICT OF INTEREST POLICY
Orange County Department of Social Services
Conflict of Interest Defined:
A conflict of interest is defined as an actual or perceived interest by a(Contractor/staff
member/Board member) in an action that results in, or has the appearance of resulting in,
personal, organizational, or professional gain. A conflict of interest occurs when an
employee/Contractor/Board member has a direct or fiduciary interest in another
relationship. A conflict of interest could include:
> Ownership with a member of the Board of Directors/Trustees or an employee
where one or the other has supervisory authority over the other or with a client
who receives services.
➢ Employment of or by a member of the Board of Directors/Trustees or an
employee where one or the other has supervisory authority over the othei or
with a client who receives services.
➢ Contractual relationship with a member of the Board of Directors/Trustees or
an employee where one or the other has supervisory authority over the other or
with a client who receives services.
➢ Creditor or debtor to a member of the Board of Directors/Trustees or an
employee where one or the other has supervisory authority over the other or
with a client who receives services.
➢ Consultative or consumer relationship with a member of the Board of
Directors/Trustees or an employee where one or the other has supervisory
authority over the other or with a client who receives services.
The definition of conflict of interest includes any bias or the appearance of bias in a
decision-making process that would reflect a dual role played by a member of the
organization or group. An example, for instance, might involve a person who is an
employee and a Board member, or a person who is an employee and who hires
family members as consultants.
Employee/Contractor/Board Member Responsibilities:
It is in the interest of the organization, individual staff, and Board members to strengthen
trust and confidence in each other,to expedite resolution of problems, to mitigate the
effect and to minimize organizational and individual stress that can be caused by a
conflict of interest.
Employees are to avoid any conflict of interest, even the appearance of a conflict of
interest. This organization serves the community as a whole rather than only serving a
special interest group. The appearance of a conflict of interest can cause embarrassment
to the organization and jeopardize the credibility of the organization. Any conflict of
interest,potential conflict of interest, or the appearance of a conflict of interest is to be
reported to your supervisor immediately. Employees are to maintain independence and
objectivity with clients, the community, and organization. Employees are called to
Conflict of Interest Policy(06/04) Pap- 1 of 2
maintain a sense of fairness, civility, ethics and personal integrity even though law,
regulation, or custom does not require them.
Acceptance of Gifts:
Employees, members of employee's immediate family, and members of the Board are
prohibited from accepting gifts, money or gratuities from the following:
a. Persons receiving benefits or services from the organization;
b. Any person or organization performing or seeking to perform services under
contract with the organization; and
c. Persons who are otherwise in a position to benefit from the actions of any
employee of the organization.
Employees may, with the prior written approval of their supervisor, receive honoraria for
lectures and other such activities while on personal days, compensatory time, annL al
leave, or leave without pay. If the employee is acting in any official capacity, honoraria
received by an employee in connection with activities relating to employment witfL the
organization are to be paid to the organization.
NOTARIZED CONFLICT OF INTEREST POLICY
State of North Carolina
County of Orange
I, G .ex/\ &P� S�� , certify that I have read the forgoing
information, understand it, and that no conflict of interest exists in the execution o:-this
contract.
Signature
Sworn to and subscribed before me on the T day of d� , 2014.
My Commission Expires:
tary Signature and Seal)
CRYSTAL BELLE COBLE
NOTARY PUBLIC
ORANGE COUNTY
NORTH CAROLINA
Conflict of Interest Policy(06/04) Pave 2 of 2
Attaclffnent E
Steven Dah Edison
1105 Hwy 54 Bypass
Apartment 1-9
Chapel Hill,NC 27516
To: Orange County Department of Social Services
Certification:
I certify that I do not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at
the federal, State, or local level. I further understand that any person who makes a false
statement in violation of N.C.G.S. 143-6.2(b2) is guilty of a criminal offense punishable
as provided by N.C.G.S. 143-34(b).
Sworn Statement:
I,being duly sworn, say that I am Steven Dah Edison; and that the foregoing certification
is true, accurate and complete to the best of my knowledge and was made and subscribed
by me. I also acknowledge and understand that any misuse of State funds will be
reported to the appropriate authorities for further action.
Signature
Sworn to and subscribed before me on the day J �", 2014.
tary oSignature"Seal)
eal) My Commission Expires:
CRYSTAL BELLE COBLE
NOTARY PUBLIC
ORANGE COUNTY
L-NORTH CAROLINA