HomeMy WebLinkAboutbocc.con.225.192017-11-13 btf
Contract Information
Contract Number
Project Name
Contractor
Budget Line Item N/A
Procurement Method:
Type:
Contract Start Date
Contract End Date
Contract Type
Retainage
If this is a new contractor, please request they complete and submit to Finance a New Vendor Request Form.
Contact Information:
Department
County Representative Kim Vallario County Representative
Phone (970) 429-2057
Provide a brief description of the contract:
Contract Value Summary:
$ -
$ -
$ -
$ -
225.19
Pitkin County
Procurement Cover Sheet
Please complete the Contract Cover Sheet when the contract/task order is complete and fully executed.
Return all Contract Cover Sheets and Contracts/Change Orders/Amendments/Task Orders to Procurement
No
QHN Systems Access, Management, and Administration
Quality Health Network ("QHN")
$ -
Additional Budget Line
Item(s)
(Please fully allocate New Contract Total)
$ -
$ -
$ -
$ -
None
Services/Maintenance
7/12/2019
7/11/2020
New Contract
NOTE: Clerks Office will keep original documents in compliance with Colorado State Archives retainage
Jail - Sheriff
QHN Systems access, management, and systems administration provided by Quality Health Networks at no
charge to County, as indicated in Attachment - Explanation of Fee Structure.
Original Contract Amount
Previous Change Order/Amendment Amount
This Change order/Amendment amount
New Contract Total
1
Product/Services Order
Exhibit B Addendum of QHN eCommerce Agreement
Quality Health Network: Product/Services Order Form. Revised 07, 2016
Executed by: _______________________________________________
Authorized Participant Signature Date
Participant / Customer Information
Name: Pitkin County Jail
Address: 506 E. Main St., Aspen, CO 81611
eCommerce Agreement Date:
Contact: Kim Vallario
Contact phone: (970) 429-2057 Contact email: kim.vallario@pitkinsheriff.com
QHN Services & Licenses for Access
Access includes : Basic HIE services, QHN Direct, Pt. Summary
Rate / Fees Quantity Total
Setup, implementation & training fees: 2
PAID FOR BY
GRANT
Travel expense (mileage at IRS allowed rate.): 0 $0
Monthly license fee: 2
PAID FOR BY
GRANT
QHN Set Up Services: Statement of Work (SOW) detail below.
Set up for 2 users to have access to QHN Results
This Order is a supplement to Exhibit B of the eCommerce Agreement executed between QHN and Participant.
Initial setup & training fees:
PAID FOR BY
GRANT
Adjustments: Grant
PAID FOR BY
GRANT
Total amount due: $0
Notes: Participants responsibility for payment will be waived as part of this program, and QHN will be responsible for
requisitioning reimbursement for services rendered to County from the grant. Up to 3 users will be allowed under this grant.
The 2 users will be Mary Pacheco and Cathie Wontor. Fees will be covered by the program as long as grant funding is
available.
Signature below authorizes delivery of products and services listed pursuant to eCommerce Agreement.
.
This Product/Services Order contains Confidential and Proprietary Information of Quality Health Network, Inc. and is
intended solely for use by the Healthcare Participant or its agents. Valid for 30 days from: 7/2/2019
Amounts will be due under this Order when Specified work is complete. Work is considered complete when system is
available for productive use. License and Services Fees are delivered pursuant to the eCommerce Agreement with QHN.
Special Fee Schedules may apply for special situations. Travel & out-of-pocket expenses are invoiced to Participant as
incurred. Add-on Users to be invoiced per then current QHN fee schedule. QHN is not responsible for any Participant
vendor fees that may apply.
Printed name: _______________________________________________
Printed name / title
Kim Vallario, Pitkin County Jail Commander
:__________________