HomeMy WebLinkAbout2017-299-E Health - Melynee Falk for regional audiology consulting services DocuSign Envelope ID: 167F763C-D16E-41 D3-B98F-F5E24EE9CC37
[Departmental Use Only]
TITLE Falk, Melynee EHDI
FY 2017-18
NORTH CAROLINA
SERVICES AGREEMENT UNDER$90,000.00
NO RFP/RFQ
ORANGE COUNTY
This Services Agreement (hereinafter "Agreement"), made and entered into this first day of
July, 2017, ("Effective Date") by and between Orange County, North Carolina a political
subdivision of the State of North Carolina (hereinafter, the "County") and Melynee Falk,
(hereinafter, the "Provider").
WITNESSETH:
That the County and Provider, for the consideration herein named, do hereby agree as
follows:
1. Services
a. Scope of Work.
i) This Agreement is for services to be rendered by Provider to County with respect
to (insert type of project): Audiology consulting services.
ii) By executing this Agreement, the 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.
iii) Time is of the essence with respect to this Agreement.
iv) The services to be performed under this Agreement consist of Basic Services, as
described and designated in Section 3 hereof Compensation to the Provider for
Basic Services under this Agreement shall be as set forth herein.
2. Responsibilities of the Provider
a. Services to be provided. The Provider shall provide the County with all services
required in Section 3 to satisfactorily complete the Project within the time limitations set
forth herein and in accordance with the highest professional standards.
b. Standard of Care.
i) The Provider shall exercise reasonable care and diligence in performing services
under this Agreement in accordance with the highest generally accepted standards
of this type of Provider practice throughout the United States and in accordance
with applicable federal, state and local laws and regulations applicable to the
performance of these services. Provider is solely responsible for the professional
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quality, accuracy and timely completion and/or submission of all work related to
the Basic Services.
ii) Provider shall be responsible for all errors or omissions of its agents, contractors,
employees, or assigns 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.
iii) The Provider shall not, except as otherwise provided for in this Agreement,
subcontract the performance of any work under this Agreement without prior
written permission of the County. No permission for subcontracting shall create,
between the County and the subcontractor, any contract or any other relationship.
iv) Provider is an independent contractor of County. Any and all employees of the
Provider engaged by the Provider in the performance of any work or services
required of the Provider under this Agreement, shall be considered employees or
agents of the Provider only and not of the County, and any and all claims that may
or might arise under any workers compensation or other law or contract on behalf
of said employees while so engaged shall be the sole obligation and responsibility
of the Provider.
v) If activities related to the performance of this Agreement require specific licenses,
certifications, or related credentials Provider represents that it and/or its
employees, agents and subcontractors engaged in such activities possess such
licenses, certifications, or credentials and that such licenses certifications, or
credentials are current, active, and not in a state of suspension or revocation.
vi) In determining the basic services to be provided, should any documents be
referenced in this Agreement, the terms of this Agreement shall have priority in
any conflict between the terms of referenced documents and the terms of this
Agreement. Should a request for proposals and a proposal be referenced the
terms of the request for proposals shall have priority over the terms of any
proposal.
3. Basic Services
a. Basic Services. The Services to be rendered pursuant to this Agreement are as follows
(fully describe services to be provided): Provide regional audiology consulting services
for the NC Early Hearing Detection and Intervention (EHDI) program to hospitals and
other public and private agencies. Follow the work plan developed by State EHDI
Program staff as stated in subsection B under section III of the Division of Public Health
Agreement Addendum FY 17-18: 324 Speech and Hearing attached as Exhibit A and
any amendments thereto, both of which are attached and hereby incorporated by
reference. Attend all DPH, C&Y Branch EHDI program training events and staff
meetings. Attend conferences and workshops as directed by the DPH C&Y Branch
EHDI program and supported by Agreement Addendum funds. Perform duties in
subsection B under section IV of Exhibit A.
4. Duration of Services
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a. Term. The term of this Agreement shall be from June 1, 2017 to May 31, 2018.
b. Scheduling of Services.
i) The Provider shall schedule and perform its activities in a timely manner.
ii) Should the County determine that the Provider is behind schedule, it may require
the Provider to expedite and accelerate its efforts, including providing additional
resources and working overtime, as necessary, to perform its services in
accordance with the approved project schedule at no additional cost to the
County.
iii) The Commencement Date for the Provider's Basic Services shall be June 1, 2017.
5. Compensation
a. Compensation for Basic Services. Compensation for Basic Services shall include all
compensation due the Provider from the County for all services under this Agreement.
The maximum amount payable for Basic Services shall not exceed Seventy Seven
Thousand Five Hundred Ninety Seven Dollars ($77,597). Payment for Basic Services
shall become due and payable within thirty (30) days of Provider properly invoicing
County. Payment shall be subject to provisions of Section 5(b).
b. Disputes. In the event the amount stated on an invoice is disputed by the County, the
County may withhold payment of all or a portion of the amount stated on an invoice
until the parties resolve the dispute. 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.
c. Additional Services. County shall not be responsible for costs related to any services in
addition to the Basic Services performed by Provider unless County requests such
additional services in writing and such additional services are evidenced by a written
amendment to this Agreement.
6. Responsibilities of the County
a. Cooperation and Coordination. The County has designated (Rebecca Crawford) to act
as the County's representative with respect to the Project and shall have the authority to
render decisions within guidelines established by the County Manager and/or the County
Board of Commissioners and shall be available during working hours as often as may be
reasonably required to render decisions and to furnish information.
7. Insurance
a. General Requirements. Provider shall obtain, at its sole expense, Commercial General
Liability Insurance, Automobile Insurance, Workers' Compensation Insurance, and any
additional insurance as may be required by County's Risk Manager as such insurance
requirements are described in the Orange County Risk Transfer Policy and Orange
County Minimum Insurance Coverage Requirements (each document is incorporated
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herein by reference and may be viewed at
http://www.orangecountync.gov/departments/purchasing division/contracts.php). If
County's Risk Manager determines additional insurance coverage is required such
additional insurance shall consist of N/A (if no additional insurance required mark N/A
as being not applicable). Provider shall not commence work until such insurance is in
effect and certification thereof has been received by the County's Risk Manager.
8. Indemnity
a. Indemnity. The Provider agrees to defend, indemnify and hold harmless the County
from all loss, liability, claims or expense, including attorney's fees, arising out of or
related to the Project and arising from property damage or bodily injury including death
to any person or persons caused in whole or in part by the negligence or misconduct of
the Provider except to the extent same are caused by the negligence or willful
misconduct of the County. It is the intent of this provision to require the Provider to
indemnify the County to the fullest extent permitted under North Carolina law.
9. Amendments to the Agreement
a. Changes in Basic Services. Changes in the Basic Services and entitlement to additional
compensation or a change in duration of this Agreement shall be made by a written
Amendment to this Agreement executed by the County and the Provider. The Provider
shall proceed to perform the Services required by the Amendment only after receiving a
fully executed Amendment from the County.
10. Termination
a. Termination for Convenience of the County. This Agreement may be terminated without
cause by the County and for its convenience upon seven (7) days' prior written notice to
the Provider.
b. Other Termination. The Provider may terminate this Agreement based upon the County's
material breach of this Agreement; provided, the County has not taken all reasonable
actions to remedy the breach. The Provider shall give the County seven (7) days' prior
written notice of its intent to terminate this Agreement for cause.
c. Compensation After Termination.
i) In the event of termination, the Provider shall be paid that portion of the fees and
expenses that it has earned to the date of termination, less any costs or expenses
incurred or anticipated to be incurred by the County due to errors or omissions of
the Provider.
ii) Should this Agreement be terminated, the Provider shall deliver to the County
within seven (7) days, at no additional cost, all deliverables including any
electronic data or files relating to the Project.
d. Waiver. The payment of any sums by the County under this Agreement or the failure of
the County to require compliance by the Provider with any provisions of this Agreement
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or the waiver by the County of any breach of this Agreement shall not constitute a
waiver of any claim for damages by the County for any breach of this Agreement or a
waiver of any other required compliance with this Agreement.
e. Suspension. County may suspend the Basic Services and this Agreement at any time for
County's convenience and without penalty to County upon three (3) days' notice to
Provider. Upon any suspension by County, Provider shall discontinue work on the Basic
Services and shall not resume the Basic Services until notified to proceed by County.
11. Additional Provisions
a. Limitation and Assignment. The County and the Provider each bind themselves, their
successors, assigns and legal representatives to the terms of this Agreement. Neither the
County nor the Provider shall assign or transfer its interest in this Agreement without the
written consent of the other.
b. Governing Law. This Agreement and the duties, responsibilities, obligations and rights
of respective parties hereunder shall be governed by the laws of the State of North
Carolina. By executing this Agreement Provider affirms that Provider and any
subcontractors of Provider are and shall remain in compliance with Article 2 of Chapter
64 of the North Carolina General Statutes. By executing this Agreement Provider
certifies that Provider has not been identified, and has not utilized the services of any
agent or subcontractor, on the list created by the State Treasurer pursuant to G.S. 147-
86.58.
c. Non-Discrimination. Provider shall at all times remain in compliance with all applicable
local, state, and federal laws, rules, and regulations including but not limited to all state
and federal non-discrimination laws, policies, rules, and regulations and the Orange
County Non-Discrimination Policy and Orange County Living Wage Policy (each policy
is incorporated herein by reference and may be viewed at
http://www.orangecountync.gov/departments/purchasing_division/contracts.php.) Any
violation of the Orange County Non-Discrimination Policy is a breach of this Agreement
and County may immediately terminate this Agreement without further obligation on the
part of the County. This paragraph is not intended to limit and does not limit the
definition of breach to discrimination.
d. Dispute Resolution. Any and all suits or actions to enforce, interpret or seek damages
with respect to any provision of, or the performance or non-performance of, this
Agreement shall be brought in the General Court of Justice of North Carolina sitting in
Orange County, North Carolina. It is agreed by the parties that no other court shall have
jurisdiction or venue with respect to such suits or actions. Binding arbitration may not
be initiated by either Party, however, the Parties may agree to nonbinding mediation of
any dispute prior to the bringing of such suit or action.
e. Entire Agreement. This Agreement represents the entire and integrated agreement
between the County and the Provider and supersedes all prior negotiations,
representations or agreements, either written or oral. This Agreement may be amended
only by written instrument signed by both parties. Modifications may be evidenced by
facsimile signatures.
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f. Severability. If any provision of this Agreement is held as a matter of law to be
unenforceable, the remainder of this Agreement shall be valid and binding upon the
Parties.
g. Ownership of Work Product. Should Provider's performance of this Agreement generate
documents, items or things that are specific to this Project such documents, items or
things shall become the property of the County and may be used on any other project
without additional compensation to the Provider. The use of the documents, items or
things by the County or by any person or entity for any purpose other than the Project as
set forth in this Agreement shall be at the full risk of the County.
h. 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 Agreement shall automatically
expire without penalty to County immediately upon written notice to Provider of the
unavailability and non-appropriation of public funds. It is expressly agreed that County
shall not activate this non-appropriation provision for its convenience or to circumvent
the requirements of this Agreement, but only as an emergency fiscal measure during a
substantial fiscal crisis.
In the event of a change in the County's statutory authority, mandate and/or mandated
functions, by state and/or federal legislative or regulatory action, which adversely affects
County's authority to continue its obligations under this Agreement, then this Agreement
shall automatically terminate without penalty to County upon written notice to Provider
of such limitation or change in County's legal authority.
i. Signatures. This Agreement together with any amendments or modifications may be
executed electronically. All electronic signatures affixed hereto evidence the consent of
the Parties to utilize electronic signatures and the intent of the Parties to comply with
Article 11A and Article 40 of North Carolina General Statute Chapter 66.
j. Notices. Any notice required by this Agreement shall be in writing and delivered by
certified or registered mail,return receipt requested to the following:
Orange County Provider's Name
Attention: Kimberlee Quatrone Melynee Falk
P.O. Box 8181 803 Seven Oaks Drive
Hillsborough,NC 27278 Greensboro, NC 27410
[SIGNATURE PAGE TO FOLLOW]
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DocuSign Envelope ID: 167F763C-D16E-41 D3-B98F-F5E24EE9CC37
IN WITNESS WHEREOF, the Parties, by and through their authorized agents, have
hereunder set their hands and seal, all as of the day and year first above written.
ORANGE COUNTY: PROVIDER:
ritlAA/Lit, Nuitoltxstui DocuSigned by: DocuSigned by:
BY: 0637994R755F477 BY' 0076FR458096410
County Manager
Melynee M. Falk, M.A., CCC-A
Printed Name and Title
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DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
Exhibit A
Division of Public Health
Agreement Addendum
FY 17-18
Page 1 of 4
Women's and Children's Health/
Orange County Health Department Children and Youth
Local Health Department Legal Name DPH Section /Branch Name
Marcia Fort 919-707-5630
324— Speech and Hearing Marcia,Fort@adhhs.nc.gov
Activity Number and Description DPH Program Contact
(name,phone number, and email)
06/01/2017—.05/31/2018
Service Period DPH Program Signature Date
(only required for a negotiable agreement addendum)
07/01/2017—06/30/2018
Payment Period
Original Agreement Addendum
n Agreement Addendum Revision#
I. Background:
Hearing loss is the most common congenital birth defect, affecting as many as three infants per thousand
born. Left undetected, hearing loss in infants can negatively impact speech and language acquisition,
academic achievement, and social and emotional development, If detected, however,these negative
impacts can be diminished and even eliminated through early intervention. Infants who fail the initial
newborn hearing screening are at a higher risk than the general population of having a hearing loss, The
most recent data from the Centers for Disease Control {CDC), for infants born in 2014, shows that
34.4% of infants in the United States and 32,7% in the state of North Carolina with a failed newborn
hearing screen are subsequently"lost to follow up."
The primary goal of the North Carolina Early Hearing Detection and Intervention{EHDI)Program is to
ensure that all infants are screened for hearing loss by one month of age; that children with congenital
hearing loss are identified by three months of age; and that all are provided access to appropriate
audiological, educational, and medical intervention by six months of age,
Regional staffing is needed to support hospital universal newborn hearing screening programs in order
to: 1) ensure that infants receive additional hearing screening when needed, 2) support families through
the diagnostic and/or intervention processes, if necessary, and 3) provide consultation, technical
assistance and resources to public and private agencies for the development and implementation of
effective Early Hearing Detection and Intervention programs. Regional staffing is also needed to
provide support and assistance to parents and families whose children have hearing loss and to provide
assistance to other professionals working with these families.
kiL--._ 74: -,751/-\ ,
Health Director Signature / (use blue ink) Date
Local Health Department to complete: LHD program contact name: :) -`CL.. (.° % (,:1-
(If follow-up information is needed by DPH) Phone number with area cop: f -2 C 2 E
Email address: E _VCtL' re S r i'; C°-C:e .:r r-'�.t t .'
Signature on this page signifies you have read and accepted all pages of this document. Revised June 2016
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
Page 2 of 4
IL Purpose:
The purpose of this Agreement Addendum is to identify and designate no more than 0.5 FTE
Audiologist to act as a Child Health Audiology Consultant (CHAC) in the north central part of North
Carolina to provide support for maintaining and improving the EHDI program. This person shall act as
part of the EHDI Team. Oversight of his or her EHDI program responsibilities will be carried out by
State EHDI Program staff.
III. Scope of Work and Deliverables:
In the counties the Local Health Department shall serve, the estimated number ofbirths for the state
fiscal year 2017-2018 is 19,800. An estimated 39 to 59°(2 to 3 per 1,000 births) of these infants will
have some form of hearing loss, and an additional 240 infants will need follow-up from newborn
hearing screening to determine their hearing status.
A. The Local Health Department shall:
1. Provide no more than one half-time (0.5 FTE) Audiologist to perform as the Division of Public
Health (DPH) Child Health Audiology Consultant (CHAC) on the EHDI team. This CHAC will
be expected to meet the program requirements as determined by the DPH, Children and Youth
(C&Y) Branch, EHDI program. The CHAC shall provide direct and indirect services to identify
and assist children with hearing loss in the following counties: Alamance, Caswell, Davidson,
Davie, Forsyth, Guilford, Orange, Randolph, Rockingham, Stokes, Surry, and Yadkin.
2. Assure that this CHAC has a master's degree in Audiology and current certification/licensure
from the American Speech-Language-Hearing Association and the North Carolina Board of
Speech Language Pathologists and Audiologists.
3. Collaborate with State EHDI Program staff to ensure that all responsibilities of the CHAC work
plan meet the standards set by the Local Health Department and the DPH, C&Y Branch EHDI
program.
4. Within five working days, notify the DPH, C&Y Branch EHDI program of any staff changes as a
result of employment termination of the person designated as the CHAC.
5. Agree not to bill families or third parties for services provided under this Agreement Addendum.
6. Ensure that the Audiologist serving as the CHAC attends all DPH, C&Y Branch EHDI program
training events and staff meetings.
7. Ensure that the designated CHAC submits the reports and monthly service logs as required by
the DPH, C&Y Branch, EHDI program,
8. Assure that the work performed by the CHAC is overseen by State EHDI Program staff.
9. Ensure that the CHAC attends conferences and workshops as directed by the DPH C&Y Branch
EHDI program and supported by Agreement Addendum funds.
10. Provide adequate workspace for the CHAC.
11. Serve as the purchasing agent for newborn hearing screening disposable testing supplies used
within the catchment area for this agreement addendum.
B. The Local Health Department's Audiologist shall follow the work plan developed by State EHDI
Program staff which will include, but is not limited to, the following activities:
1. Provide technical assistance to birthing facilities for hearing screening,rescreening and tracking
of infants born at each facility.
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Page 3 of 4
2. Provide consultation and technical assistance to public and private agencies (other stakeholders)
focusing on identification and intervention for children with hearing loss or communication
delays.
3. Provide technical assistance regarding the WCSWeb Hearing Link,North Carolina's direct data
entry and tracking system.
4. Coordinate regional educational and networking meetings about newborn hearing screening for
personnel from birthing facilities and other involved stakeholders.
5. Keep track of data concerning the efficiency and effectiveness of each birthing facility in the
region and intervene when a facility appears to be missing hearing screenings on children or has
an excessive number of children who fail the screening.
6. Identify community resources and systems that identify and refer infants and children with
suspected late onset or progressive hearing loss or communication deficits,
7. Collaborate with care managers, private providers, local health departments, and others for the
tracking of infants and children with or at risk for hearing loss.
8. Supply educational materials about hearing loss and communication delays to agencies working
with families of young children.
9. Collaborate with community resources to screen children as part of special health promotion
events or part of Head Start or other community mass screening initiatives.
10. Provide support to individual families whose children have not had a newborn hearing screening
or have failed a hearing screening to ensure that they obtain the needed repeat hearing screenings
or diagnostic evaluations to determine the absence or presence of hearing loss.
11. Provide support to individual families whose children have been diagnosed with hearing loss to
ensure that they obtain the needed intervention services and family support services.
12. Promote public awareness related to the benefits of early hearing detection and intervention.
13. Identify and develop resources for provision of services to families in a culturally appropriate
setting and in their own language.
14. Educate private providers regarding the benefits of early hearing detection and intervention and
the reporting requirements of the State.
15. Coordinate with professionals in the Early Intervention program regarding service delivery and
transition issues for children with hearing loss.
16. Collaborate with other regional consultants to identify and develop appropriate communication-
related practices, skills and techniques,
17. Consult with public and private agencies and families in the selection and procurement of
communication-related equipment and/or other assistive devices/technology.
18. Collaborate with audiologists in the expansion and development of audiology services for
children birth to 21 years, with an emphasis on early childhood,
19. Collaborate with academia to provide training opportunities for students.
20. Screen each child served directly for health insurance status and refers and assists each child's
parents or guardians to obtain needed health insurance coverage
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Page 4 of 4
IV. Performance Measures/Reporting Requirements:
A, Electronic submission of service logs is required monthly of the CHAC and are due to State EHDI
Program staff by the fifth day of the following month. The monthly services logs shall include:
1. Performance Measure #1: Evidence of at least 17 consultations, technical assistance and/or
training sessions per month provided for hospitals and other EHDI stakeholders.
2. Performance Measure #2; Evidence of timely interventions with 95% of families whose children
need follow-up from newborn hearing screening, Entries will be made in the WCSWeb Hearing
Link notes section to document counseling and education provided to families of children who
failed the newborn hearing screening, and to document consultation with their direct service
providers.
3. Performance Measure #3: Evidence of timely coordination of service delivery for children with
or at risk of hearing loss. This will include: (a) at least four in-service sessions provided to com-
munity collaborators or private providers per year; (b) at least three public awareness activities
per year; and (c) the total number of hearing screenings provided at mass screening events.
V. Performance Monitoriniz and Quality Assurance:
A. The Local Health Department shall adhere to the following Quality Assurance measures:
I, Ensure that the Audiologist is board certified,
2. Ensure that the Audiologist is licensed in North Carolina,
3. Ensure that services are provided in a culturally and linguistically appropriate manner.
B, The State EHDI Program staff will monitor the CHAC's work plan progress through;
1. Monthly reviews of electronic service logs.
2. Quarterly contacts (phone and email) with the CHAC,
3. An annual site visit with the Local Health Department, and with additional visits if needed,
4. Semi-annual review of CHAC's work plan.
5. Quarterly reviews of data on hospitals served by the CHAC from the WCSWeb Hearing Link
data tracking system.
6. Meetings with the CHAC during DPH EHDI Team Meetings and other DPH required activities.
C. Should the performance of the CHAC be inadequate-because of non-completion of expected
activities, poor communication with team members/community collaborators or insufficient
documentation, a meeting will be convened with the Local Health Department supervisor to
determine an action plan or corrective measures.
VI. Funding Guidelines or Restrictions:
A. Requirements for pass-through entities: In compliance with 2 CFR §200.331 —Requirements for
pass-through entities,the Division provides Federal Award Reporting Supplements to the Local
Health Department receiving federally funded Agreement Addenda.
1. Definition: A Supplement discloses the required elements of a single federal award, Supplements
address elements of federal funding sources only; state funding elements will not be included in
the Supplement Agreement Addenda (AAs) funded by more than one federal award will receive
a disclosure Supplement for each federal award,
2. Frequency: Supplements will be generated as the Division receives information for federal
grants. Supplements will be issued to the Local Health Department throughout the state fiscal
year, For federally funded AM, Supplements will accompany the original AA. If AAs are
revised and if the revision affects federal funds, the AA Revisions will include Supplements.
Supplements can also be sent to the Local Health Department even if no change is needed to the
AA. In those instances, the Supplements will be sent to provide newly received federal grant
information for funds already allocated in the existing AA.
Revised June 2016
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
12/2/2016 WlcGridPrint
DPH-Aid-To-Counties For Fiscal Year:17/18 Budgetary Estimate Number:0
Activity 324 AA 1332 324 Proposed New
5390 5390 Total Total
99 99
Service Period 06101-05/3106101-05131
Payment Period 07/01-06/30 07101.06130
01 Alamance 0 0 0 0
D1 Albemarle * 0 106,084 0 106,084106,084
02 Alexander 0 .0 0 0
04 Anson 0 0 0 0
D2 Appalachian 0 0 0 0
07 Beaufort 0 0 0 0
09 Blades 0 0 0 0
10 Brunswick 0 0 0 0
11 Buncombe 0 0 0 0
12 Burke 0 0 0 0
13 Cabarrus 0 0 0 0
14 Caldwell 0 0 0 0
16 Carteret 0 0 0 0
17 Caswell 0 0 0 0
18 Catawba 0 0 0 0
19 Chatham 0 0 0 0
20 Cherokee- 0 0 0 0
22 Clay 0 0 0 0
23 Cleveland 0 0 0 0
24 Columbus 0 0 0 0
25 Craven 0 0 0 0
26 Cumberland 0 0 0 0
28 Dare r 0 0 0 0
29 Davidson 0 0 0 0
30 Davie 0 0 0 0
31 Duplin 0 0 0 0
32 Durham 0 0 0 a
33 Bdgecombe 0 0 0 0
34 Forsyth 0 0 0 0
35 Franklin 0 0 0 0
36 Gaston 0 0 0 0
38 Graham 0 0 0 0
D3 Gran-Vance 0 0 0 0
40 Greene 0 0 0 0
41 Guilford 0 0 0 0
-r-42 Halifax .. a - { 0 - 01
43 Harnett 0 0 0 0
'44 Haywood 0 0 0 0
45 Henderson 0 0 0 0
46 Hertford 0 0 0 0
47 Hoke 0 0 0 0
48 Hyde 0 . 0 0 0
49 lredell 0 0 0 0
50 Jackson 0 0 0 0
http://atc.cihhs.state,nc.us/WICGridPrintaspx 1/2
DocuSign Envelope ID: 167F763C-D16E-41 D3-B98F-F5E24EE9CC37
1212/2016 WicGridFrint
51 Johnston 0 0 0 0'
52 Jones 0 0 0 0
53 Lee 0 0 0 0
54 Lenoir 0 0 0 0
5s Lincoln 0 0 0 0
56 Macon 0 0 0 0
57 Madison 0 0 0 0
D4'M-T W 0 0 0 0
60 Mecklenburg 0 0 0 0
62 Montgomery 0 0 0 0
63 Moore 0 0 0 0
64 Nash 0 0 0 0
65 New Hanover 0 0 0 0
66 Northampton .0 0 0 0
.67 Onslow 0 0 0 0
68:Orange 0 , 49,110 0 49,110 49,110
69 Pamlico 0 0 0 0
71 Pender 0 0 0 0
73:Person 0 0 0 0
74 Pitt 0 0 0 0
76 Randolph . 0 0 0 0
77 Richmond 0 0 0 0
78 Robeson 0 0 0 0
79 Rockingham . 0 0 0 TO
80 Rowan 0 0 0 0
D5 R-P-M 0 0 0 0
82 Sampson 0 0 0 0 .
83 Scotland 0 0 0 0
84 Stanly 0 0 0. 0
SS Stokes 0 0 0 0
66 Surry 0 0 0 0
87 Swain 0 0 0 0
D6 Toe River 0 0 0 0
88 Transylvania 04 0 0 _ 0
_90 Union 0 0 0 0 .
92 Wake 0 0 0 0
93 Warren 0 0 01 0
96 Wayne 0 0 0 0
97 Wilkes 0 0 0 0
98 Wilson _ 0 0 0 0
99 Yadkin 0 0 0 0
Totals 155;.194 0 155,194155,194
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http:C late,dhhs.stett&,nc.usalCGridPrint.aspx 2/2
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
Federal Award Reporting Requirements for Pass-Through Agencies,2 CFR§200,331
FY18 Activity: 324 Speech and Hearing Supplement 1
Supplement reason: ® in AA+BE or AA+BE Rev -OR- ❑ -
CFDA#: 93J78 Federal awd date: unknown Is award R&D? no FAIN: unknown Total amount of fed awd: $ unknown
Fed award
project Medicaid Administration Payments
CFDA description:
name:
Medical Assistance Progam(Medicaid:Title XIX)
Fed awarding DHHS,Centers for Medicare& Federal award n/a
agency: Medicaid Services indirect cost rate: 9/
Subreciplent Subrecipient Fed funds for Total All fed funds Subrecipient Subreciplent Fed funds for Total All fed funds
DUNS this Supplement for this Activity DUNS this Supplement for this Activity
Alamance 965194483 = = Jackson 019728518 = _
Albemarle 130537822 45404 45404 Johnston 097599104 =
Alexander 030495105 = = Jones 095116935 = _
Anson 847163029 = = Lee 067439703 = -
Appalachian 780131541 = = Lenoir 042789748 = =
Beaufort 091567776 = = Lincoln 086869336 = =
Bladen 084171628 = = Macon 070626825 = -
Brunswick 091571349 = = Madison 831052873 - _
Buncombe 879203560 = = MTW 087204173 - _
Burke 883321205 = = Mecklenburg 074498353 = _
Cabarrus 143408289 = = Montgomery 025384603 = _
Caldwell 948113402 = = Moore 050988146 =
Carteret 058735804 = _ Nash 050425677 =
Caswell 077846053 = = New Hanover 040029563 = =
Catawba 083677138 = = Northampton 097594477 = =
Chatham 131356607 = = Onslow 172663270 = =
Cherokee 130705072 = = Orange 139209659 21020 21020
Clay 145058231 = = Pamlico 097600456 =
Cleveland 879924850 = = Pender 100955413 = _
Columbus 040040016 = = Person 091563718 = _
Craven 091564294 = = Pitt 080889694 = _
Cumberland 123914376 = = Randolph 027873132 = _
Dare 082358631 = = Richmond 070621339 = _
Davidson 077839744 = = Robeson 082367871 = _
Davie 076526651 = = Rockingham 077847143 = =
Duplin 095124798 = = Rowan 074494014 - =
Durham 088564075 = = RPM 782359004 = _
Edgeco m be 093125375 = = Sampson 825573975 = _
Forsyth 105316439 = = Scotland 091564146 = _
Franklin 084168632 = = Stanly 131060829 = _
Gaston 071062186 = = Stokes 085442705 = _
Graham 020952383 = = Surry 077821858 = _
Granville-Vance 063347626 = = Swain 146437553 =
Greene 091564591 = = Toe River 113345201 -
Guilford 071563613 = = Transylvania 030494215 =
Halifax 014305957 = = Union 079051637 = _
Harnett 091565986 = = Wake 019625961 =
Haywood 070620232 = = Warren 030239953 = _
Henderson 085021470 = = Wayne 040036170 = _
Hertford 627320971 = = Wilkes 067439950 = _
Hoke 091563643 = = Wilson 075585695 = _
Hyde 832526243 - = Yadkin 089910624 = =
iredell 074504507 = =
OPH v1.2 5-27-16
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
Division of Public Health
Agreement Addendum
FY17-18
Page 1 of 2
Women's and Children's Health/
Orange County Health Department Children and Youth
Local Health Department Legal Name DPH Section /Branch Name
Marcia Fort 919-707-5630
324—Speech and Hearing Marcia.Fort@dhhs.nc.gov
Activity Number and Description DPH Program Contact
(name,phone number,and email)
06/01/2017—05/31/2018
Service Period DPH Program Signature Date
(only required for a negotiable agreement addendum)
07/01/2017---06/30/2018
Payment Period
Original Agreement Addendum
® Agreement Addendum Revision# 1
I. Background:
No change.
II. Purpose:
This Agreement Addendum Revision#1 increases funding to increase the FTE for the Child Health
Audiology Consultant(CHAC).Additional funds are provided for maintenance, replacement, or
purchase of equipment used for hearing screening and rescreening and to cover the cost for the CHAC to
attend the National Early Hearing Detection and Intervention Meeting in March 2018 in Denver,
Colorado.
III. Scope of Work and Deliverables:
As of June 1, 2017, this Agreement Addendum Revision #1 adds the following sentence to
Subparagraph 1 of Paragraph A:
With this Agreement Addendum Revision#1, the Local Health Department shall increase by
0.25 FTE the Child Health Audiology Consultant, to a revised total of 0.75 FTE.
As of June 1, 2017, this Agreement Addendum Revision #1 adds Subparagraphs 12 and 13 to
Paragraph A, as follows:
12. Serve as purchasing agent for maintenance, replacement or purchase of equipment used for
hearing screening and rescreening to the extent possible with the funds provided with this
Agreement Addendum.
•
Health Director Signature (use blue ink) Date
Local Health Department to complete: LHD program contact name: C..- ,v.,ifL,fc4
(If follow-up information is needed by DPH) Phone number with area code: Ott 2_ 2_4 v
Email address: (`c.r r yr Oro, ,a r"lt
.J �J
Signature on this page signifies you have read and accepted all pages of this document. Revised June 2016
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
Page 2 of 2
13. Ensure the CHAC attends the National Early Hearing Detection and Intervention(EHDI)
Meeting in March 2018 in Denver, Colorado.
IV. Performance Measures/Reporting Requirements:
No change.
V. Performance Monitoring and Quality Assurance:
No change.
VI. Funding Guidelines or Restrictions:
No change.
Revised June 2016
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
Federal Award Reporting Requirements for Pass-Through Agencies,2 CFR§200331
FY18 Activity: 324 Speech and Hearing Supplement 2
Supplement reason: ® In AA+BE or AA+BE Rev -OR- 0 -
CFDA#: 93.778 Federal awd date: unknown is award R&D? no FAIN: unknown Total amount of fed awd: $ unknown
Fed award
project Medicaid Administration Payments
CFDA Medical Assistance Progam(Medicaid:Title MX) description:
name: •
Fed awarding DHHS,Centers for Medicare& Federal award % .
•
agency: Medicaid Services indirect cost rate: n/a
Subrecipient Subrecipient Fed funds for Total All fed funds Subrecipient Subrecipient Fed funds for Total All fed funds
DUNS this Supplement for this Activity DUNS this Supplement for this Activity
Alamance 965194483 = = Jackson 019728518 = =
Albemarle 130537822 -12192 33212 Johnston 097599104
Alexander 030495105 = = Jones 095116935 = =
Anson 847163029 = = Lee 067439703 - = •
Appalachian 780131541 = = Lenoir 042789748 = = •
•
Beaufort 0915 67776 = = Lincoln 086869336 = _ •
•
Bladen 084171628 = = Macon 070626825 = = •
Brunswick 091571349 = = Madison 831052873 = _
Buncombe 879203560 = = MTW 087204173 = =
Burke 883321205 = = Mecklenburg 074498353 = =
Cabarrus 143408289 = = Montgomery 025384603 =
Caldwell 948113402 = = Moore 050988146 = =
Carteret 058735804 = = Nash 050425677 = _
Caswell 077846053 = = New Hanover 040029563 = =
Catawba 083677138 = = Northampton 097594477 = =
Chatham 131356607 = = Onslow 172663270 = =
Cherokee 130705072 = = Orange 139209659 12192 33212
Clay 145058231 = = Pamlico 097600456 = =
Cleveland 879924850 = = Pender 100955413 = =
Columbus 040040016 = = Person 091563718 = =
Craven 091564294 = = Pitt 080889694 = =
Cumberland 173914376 = = Randolph 027873132 = =
Dare 082358631 = = Richmond 070621339 = =
Davidson 077839744 = = Robeson 082367871 = =
Davie 076526651 = = Rockingham 077847143 = _
Duplin 095124798 = = Rowan 074494014 = =
Durham 088564075 = = RPM 782359004 = _
Edgecombe 093125375 = = Sampson 825573975 = =
Forsyth 105316439 = = Scotland 091564146 = =
Franklin 084168632 = = Stanly 131060829 =
Gaston 071062186 = = Stokes 085442705 = =
Graham 020952383 = = Surry 077821858 = _
Granville-Vance 063347626 = = Swain 146437553 = =
Greene 091564591 = = Toe River 113345201 = _
Guilford 071563613 - = Transylvania 030494215 = =
Halifax 014305957 = = Union 079051637 = =
Harnett 091565986 = = Wake 019625961 =
Haywood 070620232 = = Warren 030239953 = =
Henderson 085021470 = = Wayne 040036170 =
Hertford 527320971 = = Wilkes 067439950 =
Hoke 091563643 = = Wilson 075585695 = =
Hyde 832526243 = = Yadkin 089910624 . _ =
I redel I 074504507 = =
•
PPH v1.2 5-27-16
DocuSign Envelope ID: 167F763C-D16E-41 D3-B98F-F5E24EE9CC37
WicGridPrint Page 1 of
DPHAid-To-Counties For Fiscal Year: 17118 Budgetary Estimate Number: '1
Activity 324 AA 1332 324 Proposed New
5390 5390 Total Total
' 99 99
Service Period 06/01-05/31 06101-05131
Payment Period 07/01-06/30 07/01-06/30
01 Alamance 0 0 0 0
D1 Albemarle * 1 -28,487 0 -28,487 77,597
02 Alexander 0 0 0 0
04 Anson 0 0 0 0
D2 Appalachian 0 0 0 0
07 Beaufort 0 0 0 0
09 Bladen 0 0 0 0
10 Brunswick 0 ' 0 0 0
11 Buncombe 0 0 0 0
12 Burke 0 0 0 0
13 Cabarrus 0 0 0 0
14 Caldwell 0 0 0 0
16 Carteret 0 0 0 0
17 Caswell 0 0 0 0
18 Catawba 0 0 0 0
19 Chatham 0 0 0 0
20 Cherokee 0 0 0 0
22 Clay 0 0 0 0
23 Cleveland 0 0 0 0
24 Columbus 0 0 0 0
25 Craven 0 0 0 0
26 Cumberland 0 0 0 0
28 Dare 0 0 0 0
29 Davidson 0 0 0 0
30 Davie 0 0 0 0
31 Duplin 0 0 0 0
32 Durham 0 0 0 0
33 Edgecombe 0 0 0 0
34 Forsyth 0 0 0 0
35 Franklin 0 0 0 0
36 Gaston 0 0 0 0
38 Graham 0 0 0 0
D3 Gran-Vance _ 0 0 0 0
40 Greene 0 0 0 0
_
41 Guilford 0 0 0 0
42 Halifax 0 0 0 0
43 Harnett 0 0 0 0
44 Haywood 0 0 0 0
45 Henderson 0 0 0 0
46 Hertford 0 0 0 0
47 Hoke 0 0 0 0
http://atc.dhhs.state.nc.us/WICGridPrint.aspx ; 5/25/2017
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
WicGridPrint Page 2 of 2.
148 Hyde 0 0 0 0
49 l redel l 0 0 0 0
50 Jackson 0 0 0 0
51 Johnston 0 0 0 0
52 Jones 0 0 0 0
53 Lee 0 0 0 0
54 Lenoir 0 0 0 0
55 Lincoln 0 0 0 0
56 Macon 0 0 0 0
57 Madison 0 0 . 0 0
D4 M-T-W 0 0 0 0
60 Mecklenburg 0 . 0 0 0
62 Montgomery 0 0 0 0
63 Moore 0 0 0 0
64 Nash 0 0 0 0
65 New Hanover 0 0 0 0
66 Northampton 0 0 0 0
67 Onslow 0 0 0 . 0
68 Orange * 1 28,487 0 28,467 77,597
69 Pamlico 0 0 0 0
71 Pencler 0 0 0 0
73 Person 0_ 0 0 0
74 Pitt 0 0 0 0
76 Randolph 0 0 0 ' 0
77 Richmond 0 0 0 0
78 Robeson 0 0 0 0
79 Rockingham 0 0 0 0
80 Rowan 0 0 0 0
D5 R-P-M 0 0 0 0
_82 Sampson 0 0 0 0
83 Scotland 0 0 0 0
84 Stanly 0 0 0 0
85.Stokes 0 0 0 0
86 Sorry 0 0 0 0
87 Swain 0 0 0 0
D6 Toe River 0 0 0 0
88 Transylvania 0 0 0 0
90 Union 0 0 0 0
92 Wake 0 0 0 0
93 Warren 0 0 0 0
96 Wayne 0 0 0 0
97 Wilkes 0 0 0 0
98 Wilson 0 0 0 0 79. 1 I /1
99 Yadkin 0 0 0 0
Totals 0 0 0155,194
Sign and Oat -DPH Program Administrator _ Sign *ate-DPH cC ief
..�- - '- -—'7 ction __ .7//46//1 7
-, ,),,,,,-,, N-le--- (N\0-0,kyvA-tibkkc- . ;10,y-ck c`x&rie..:24.-Z,‘,,12, t,lit-,4,&
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http.//atc.dhhs.state.nc.us/WICOridPrint.aspx 5/25/2017
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
APM 8231172 4738
NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611.7427 PERSONAL AUTO POLICY
AMENDED DECLARATION 01 * * EFFECTIVE 05/16/17
REASON FOR AMENDMENT SEE DETAILED CHANGES
4g NUMBEI tgrR4 O M�ER
M B iIP NI ENAGT obg
APM 8231172 04/24/17 10/24/17 1984848 APM DECL 0515 0794227
AMED ENSUE AND ADDRESPr ....:.',... ...:_ AGEN1 . .:.::... ....... ' r
GARY FALK
MELYNEE FALK
803 SEVEN OAKS DR JOHN G EDWARDS, LUTCF
GREENSBORO, NC 27410-4656 TELE: (336) 623-1025
203 E HARRIS FL
EDEN, NC 27288-5329
VEHICLES COVERED TYPE SYMBOL STATED
VEH ZIPCD YR MAKE VEH SERIAL NUMBER CMPCOL OCN AMT. CLA SDIP
001 27410 01 JEEP WRNGLR SAH PP 1J4FA59S71P303580 1616 1B 00
002 27410 10 GMC YUKON XL 1 PP 1GKUKKE36AR118016 1515 1A 00
003 27410 01 GMC YKNSLE/SLT PP 1GKEK13T61J278879 1212 1A 00
INSURANCE IS PROVIDED WHERE A PREMIUM IS SHOWN FOR THE COVERAGE.
COVERAGE LIMITS OF LIABILITY PREMIUMS
UNIT 1 2 3
A BODILY INJURY $300, 000 EA PERSON $500, 000 EA ACC 73. 92 70 . 92 289.92
A PROPERTY DAMAGE $100, 000 EACH ACCIDENT 54 . 92 51 . 92 190. 92
B MEDICAL PAYMENTS $2, 000 PER PERSON 6. 00 5. 00 29 .00
D OTHER THAN COLLISION $0 DEDUCTIBLE 29. 00 26.00
D COLLISION $500 DEDUCTIBLE 59.00 70.00
TOWING & LABOR 7 . 00 7.00
EXTENDED TRANSPORTATION $30/DAY $900 MAX 10 . 00 10 . 00
RENTED VEHICLE COVERAGE - FULL 2 . 00
TOTAL BY UNIT 241 . 84 240 .84 509. 84
C2 UNINS/UNDERINS MTR BI $100, 000 EA PER $300, 000 EA AC $64 . 00
UNINSURED MOTORIST - PROPERTY DAMAGE $50, 000 $4 . 00
TOTAL TERM PREMIUM $1, 060.52
THIS PREMIUM REFLECTS A FARM BUREAU DISCOUNT FOR THE FOLLOWING:
-PREFERRED -MULTICAR POLICY
-PROPERTY COVERAGE WITH FARM BUREAU -FULL PAY PLAN
-PROTECTION PLUS
AIRBAG DISCOUNT APPLIED UNIT 1,2, 3.
IPLBASE R VIEW YOUR POLICY DECLAI TTO AND POL.IC
IFROVSTON C EF 1LL' i CONTACT FOUR tEN`` .L ` YOU 'HAVI AMY
iQUSTTOIS OR CAGED
WE APPRECIATE YOUR BUSINESS.
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
APM 8231172 4739
NORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 PERSONAL AUTO POLICY
AMENDED DECLARATION 01 * * EFFECTIVE 05/16/17
REASON FOR AMENDMENT SEE DETAILED CHANGES
FA7 tGY F bfl MBE Htlz O
f.fP NJIyfggfa, ROr .:.. ...T o WN M+4G E
APM 8231172 04/24/17 10/24/17 1984848 APM DECL 0515 0794227
GARY FALK
MELYNEE FALK
803 SEVEN OAKS DR JOHN G EDWARDS, LUTCF
GREENSBORO, NC 27410-4656 TELE: (336) 623-1025
203 E HARRIS PL
EDEN, NC 27288-5329
DRIVER ID DRIVER NAME
01 GARY FALK
02 MELYNEE FALK
03 DAVIS BENJAMIN FALK
INEXPERIENCED PRINCIPAL OPERATOR VEHICLE 3 DATE LICENSED 05/16/17
APPLICABLE FORMS
FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT
APMNC 01/10 ALL NC0301 07/87 ALL NC0013 04/16 ALL NC0304 01/98 001
NC0302 01/99 001 NC0330 01/14 001 NC0304 01/98 002 NC0302 01/99 002
OTHER POLICIES FOR MEMBERSHIP NUMBER 1984848 :
POLICY INSURED NAME
UP 0056864 GARY FALK
HP 6165421 GARY FALK
DocuSign Envelope ID: 167F763C-D16E-41D3-B98F-F5E24EE9CC37
APM 8231172 4740
rNORTH CAROLINA FARM BUREAU MUTUAL INSURANCE COMPANY PART B DECLARATION PAGE
P.O.BOX 27427 RALEIGH,NORTH CAROLINA 27611-7427 PERSONAL AUTO POLICY
AMENDED DECLARATION 01 * * EFFECTIVE 05/16/17
REASON FOR AMENDMENT SEE DETAILED CHANGES
E .Mg#lore .... _ MEMBER HI 1O
��.iD1�NUMBER �ROtir � _...:::._ ....... ....:... ::.............
APM 8231172 04/24/17 10/24/17 1984848 APM DECL 0515 0794227
_Id MED INS(l ND, f.... .PR ..... : .... .....' :..:.::..... ACS.......
GARY FALK
MELYNEE FALK
803 SEVEN OAKS DR JOHN G EDWARDS, LUTCF
GREENSBORO, NC 27410-4656 TELE: (336) 623-1025
203 E HARRIS PL
EDEN, NC 27288-5329
I
DETAILED CHANGES:
ADD DRIVER
ADD POINTS OR INEXPERIENCED OPERATOR
X/21 /30/17
AUT DATE
1
DocuSign Envelope ID: 167F763C-D16E-41 D3-B98F-F5E24EE9CC37
CI i ent #2271544
MEMORANDUM OF INSURANCE Date Issued 03/27/2017
Producer This memorandum is issued as a matter of information
only and confers no rights upon the holder. This
Mercer Consumer, a service of memorandum does not amend, extend or alter
Mercer Health& Benefits Administration LLC coverages afforded by the Certificate listed below.
P.O. Box 14576
Des Moines, IA 50306-3576
1-800-503-9230 Company Affording Coverage
Insured Liberty Insurance Underwriters Inc
M el ynee M Fal k
803 Seven Oaks Drive
Greensboro NC 27410
This is to certify that the Certificate listed below has been issued to the insured named above for the policy period indicated,
not withstanding any requirement, term or condition of any contract or other document with respect to which this
memorandum may be issued or may pertain, the insurance afforded by the Certificate described herein is subject to all the
terms, exclusions and conditions of such Certificate. The limits shown may have been reduced by paid claims.
Type of Insurance Certificate Number Effective Date Expiration Date Limits
Professional Liability AHY-860875001 04/01/2017 04/01/2018 Per Incident/ $1,000,000
SpeechLangH SE Occurrence
Speech Language Pathologist
Annual Aggregate $3,000,000
PROOF OF INSURANCE
Memorandum Holder: Should the above describe Certificate be cancelled
before the expiration date thereof,the issuing company
PROOF OF COVERAGE ONLY will endeavor to mail 30 days written notice to the
Memorandum Holder named to the left, but failure to
mail such notice shall impose no obligation or liability
of any kind upon the company, its agents or
representatives.
Authorized Representative
Mark Brostowitz
�Y l a -QL Q. ' ,;-•raw!
Mercer Consumer, a service of Mercer Health& Benefits Administration LLC. I n CA d/b/a Mercer Health& Benefits Insurance Services LLC. CA Ins L i c. #0G39709