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Agreement with OCEHS for Dental Services <br />FY 2009-2010 <br />following: <br />A) Dental health education for children <br />B) Dental health education for parents, including meeting with a dental staff <br />member and individual parents of children requiring follow-up treatment <br />C) Dental health education for staff <br />D) Suggestions for classroom activities <br />E) Hand-outs to be taken home by the children <br />5. OCHD will complete the CAP-H.S.S.-30 forms pertaining to dental health and return the <br />forms to OCHS/EHS to be made a part of the child's permanent Head Start record. <br />6. OCHD will file for Medicaid/other third party insurance plans for reimbursement when <br />necessary (OCHS/EHS is not a health provider, therefore cannot file). <br />7. OCHD will submit a bill to Angela Wilcox, Director, OCHS/EHS, in the amount of $8,000 <br />on an annual basis. OCHS/EHS agrees to pay the OCHD in two installments, $4,000 by <br />December 31, 2009 and the remaining $4,000 by June 30, 2010, upon receipt of OCHD original <br />invoice. The check should be made payable to Orange County Health Department and mailed to <br />Letitia Burns, Central Administrative Services Director, PO Box 8181, Hillsborough, NC. <br />8. OCHS/EHS agrees as follows: <br />a. To transport no more than 5-10 children to be scheduled at least every other week <br />on a block basis and to provide adequate supervision in the waiting room. OCHS/EHS shall be <br />responsible for obtaining and maintaining adequate automobile liability insurance as required by <br />law and if requested will furnish to the County certificates of such insurance. <br />b. To arrive for the scheduled appointments on-time with all children scheduled for <br />that day. OCHS/EHS shall be responsible for re-scheduling any appointments unable to be met <br />at least 24 hours in advance. <br />c. To provide necessary parental permissions, information for the Eligibility <br />Determination forms, and the Medical and Dental Histories for each child prior to that child <br />undergoing treatment. OCHS/EHS will bring alt signed forms on the day of service. <br />d. To provide CAP-H.S.S.-30 forms pertaining to dental health and will make the <br />completed form a part of the child's permanent OCHS/EHS record. <br />e. To obtain a copy of each child's Medicaid card or other dental insurance and bring <br />a copy to the OCHD on the scheduled day of service. <br />9. In the event that enrollment in OCHS/EHS program ceases or is significantly reduced <br />during the term of this agreement, OCHS/EHS may terminate this agreement upon 30 days notice <br />and OCHD will return a pro rata share of the payment for services not provided (approximately <br />$100 per enrolled child for those children whose dental work has not been started). <br />10. The parties agree that there shall be no unlawful discrimination based upon race, color, <br />ancestry, national origin, religion, sex, age, disability or veteran status. <br />11. The parties agree to abide by HIPAA regulations in the sharing of protected health <br />Page 3 of 4 <br />S:\Managers Working Files\Contracts\DENTAL\FY 09 Head Start Contract\09-10 Head Start Dental <br />Contract.doc <br />