COURT ORDER BE IT REMEMBERED, at a regular meeting of Commissioners' Court of Dallas County, Texas held on the 26 TH day of __ -'-Fe""b""r."u"'arv'-1-____________ 2013, on motion made by ____________________________________ , and seconded by ____________________________ , the following Order was adopted: WHEREAS, the award of FY 2012 Ryan White Part A Formula funds was discussed in Commissioners Court on February 19, 2013; and WHEREAS, FY 2012 Ryan White Part A Formula funds in the amount of $356,500, are recommended for award approval to service providers reflected in Attachment A; and WHEREAS, the Ryan White Part A Formula grant directly supports a regional indigent medical and mental healthcare network for those impacted by HIV/AIDS and is consistent with the Dallas County Strategic Plan, Vision 2: Dallas County is a healthy community; and WHEREAS, the Commissioner Court must approve the contract amendment with the service providers and authorize the County Judge to sign the amendments on behalf of Dallas County, IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that the Dallas County Commissioners Court does hereby approve the award of FY 2012 Ryan White Part A Formula funds in the amount of $356,500, to service providers as reflected in Attachment A, and authorizes the County Judge to sign the Amendments with the specific service providers on behalf of Dallas County, DON E I N OPEN CO U RT th is the --=2""6t""h'---___ day of __ --'-F.",e"'-br'-"u""a""'rvc-_____ , 2 0 1 3, Clay Lewis Jenkins County Judge Dr. Theresa M, Daniel Commissioner, District No, 1 Mike Cantrell Commissioner, District No, 2 John Wiley Price Commissioner, District No, 3 Recommended by: Dr. Elba Garcia Commissioner, District No, 4 ATTACHMENT A FV 2012-2013 Ryan White Part A Formula Award AGENe, INITlAL O""MGL TOTAL . .....
Ams ,. I 26iJi11 ".378
604.182 "".182 AIDS Arms, Inc. 374. 374."" i
, . ' .... i i 46.'" AIDS Interfaith Network, Inc. M,di,,,1 I 354."8 354,8(,8 , 42.'" 42';47 C"" M
/I,m, lloh",," M,,'. 155.,,;7 "'.657 AIDS Services of Dallas M,d",1 C", 133.'"'' 133.'09
, . 63.170 63.170
AIDS 29'i,J65 299.:;(,:; c," .. 89.458 89.458 row" 67.364 67.3<,4 Health Services of North 129.'" Texas, Inc.
i' """III,,,tI, .... ," Dallas County Health Division
@
AmS '1..l78 . i ' M,di,,1 c,,' 1.'55.11 1(,4/," 1.619.7.1(, Dallas County H ospita1 District c,,' 135.111" &i.l25 '''.144 d.h.a. Parkland I "",,' 388.2" Health and Hospital System ".,. iI Dallas Legal Hospice
a D,""III",tI. .1",. TOTAL I
Home Health Service:; lI"m, ,"d C i ! i I ) e.,, 48.103 . 1I,,",i,, B,,,
e", H,m, D,hv",d ""I. IN.13'i Legacy Counseling Center M""'II,,ltb 75."" 75.64: "\h",, . 6(,.411< . In" C"" 25.'12" d.h.a. Bryan's House Child em S"'''" 1.195 1.1'" R"pi" em "". Child",,!' , 25.328 25.328 TOTAL
Resource Center of Dallas, Inc. 8>4.352 d.h.a. AIDS Resource Center M,di"I' . , . 92."" 925" 0,,1 H,,,lth em .J4239S 342.39'
I I F"d. 01'1l I 356.'00 (356,SOOI I F""d, UTAL ,AWARD 356,'00 . 8,798,819 i' , 880.420 , OM .. CIi,,,. R.,;," (,0.000 = ;TOTALH
. 9.944.346 21812013 DALLAS COUNTY HEALTH AND HUMAN SERVICES GRANTS MANAGEMENT ZACHARY THOMPSON DIRECTOR TO: Zachary Thompson FROM: Aurelio Rodriguez DATE: February 8, 2013 SUB.IECT: 2012-2013 Ryan White Part A Formula Contract Amendment is ready. CONTRACTOR NAME: AIDS Arms, Inc., GRANT PROGRAM: FY 2012-2013 Ryan White Part A Formula The attached budget was reviewed by Grants Management staff and is ready for signature. The following items were verified: ITEM 1. 2. 3. 4. 5. 6. Amount corresponds with Briefing and Court Order documents. All five originals signed by appropriate agent of organization. Budget Exhibits A are calculated conectly. Performance Objectives, Exhibit B-1, contains appropriate units of service. Multiple Funding Sources, Exhibit C, contains updated funding infonuation. All budget fonus appropriately entitled with agency name, address, and federal ID number. 2377 Stemmons Freeway C::l1;tp ?nn T R_l h Dallas, Texas 75207-2710 Office (214) 819-1842 l:'AV r,")ltl\ 01() t:{\")') I CONTRACT AMENDMENT NO.3 CONTRACT FOR HIV/AIDS SERVICES DELIVERY FUNDED UNDER THE FY 2012 TITLE XXVI OF THE PHS ACT, AS AMENDED BY THE RYAN WHITE HIV/AIDS TREATMENT EXTENSION ACT OF 2009: PART A FORMULA FUNDING GRANT CATALOG OF FEDERAL DOMESTIC ASSISTANCE (CDFA) NO. 93.914 Between DALLAS COUNTY HEALTH & HUMAN SERVICES (Contractor) I. PURPOSE: and AIDS Arms, Inc. (Snb-Contractor) Contract Amendment No.3 amends the HIV / AIDS Services Delivery Funded under the FY 2012 Title XXVI of the PHS Act, as amended by the Ryan White HIV / AIDS Treatment Extension Act of2009: Part A Formula grant agreement executed between Dallas County Health & Human Services and AIDS Arms, Inc., effective March 1,2012. II. AMENDED PROVISIONS: Contract Amendment No.3 shall not change any contractual provisions agreed upon in the Ryan White HIV/AIDS Treatment Extension Act Part A Formula funded agreement; each provision shall remain in effect throughout the term of the agreement with the exception of the following amended provisions: A: AMENDED CONTRACT AMOUNT: The contract payment provisions are revised to increase funds in the amount of $51,378 in AIDS Pharmaceutical Assistance. The total contract is increased to $1,595,185. Original Part A Formula grant contract amount: Award due to Amendment No.1: Award due to Amendment No.2: Award due to Amendment No. 3: Total amended contract amount: $1,510,619.00 $ 21,432.00 $ 11,756.00 $ 51,378.00 $1,595,185.00 For: B: AMENDED PROVISIONS: The revised Exhibit A-I (detailed for the line item service budget), A-3 (budget justification), B-I(perfonnance objectives), and CI and C2 (multiple funding sources) reflect increased funding in the AIDS Phannaceutical Assistance service category. C. TERM: Contract Amendment No.3 shall not affect the original term of the contact that is in effect through February 28, 2013. AIDS Arms, Inc. (Signat (Print or type name) P C(2 flnt or type It e Date: __ t-_+-'-______ _ For: Dallas County Health and Human Services Date Clay Lewis Jenkins Dallas County Judge Date: ___________ _ AIDS ARMS, INC. 351 WEST JEFFERSON BLVD SUITE 300 DALLAS TX 75208-4599 FEIN: 75-2306145 EXHIBIT A1 (a): DETAILED LINE ITEM BUDGET FOR DIRECT COST AGENCY: AIDS ARMS, INC, GRANT:Ryan White Part A Formula SERVICE CATEGORY: Local AIDS Pharmaceutical Assistance GRANT PERIOD: March 1, 2012 to February 28, 2013 A 1 Simpson Jlsnomas IAnole Ibarra 8 11: 114 111 116 111 ,rURE ITEMS I I TITLE enefits i 'ene"ts I >ala Suppen lirector of I ::Iinic , i i I 1& Dala B DOC 20% 2> 1> D ',120 ,12C ,23C ,34C .068
'. _.-'-< ............. " .. '
IC;2"'11i::in:. ",:':ii.: I' .... ." -;ce. '., ' .. I DITURE 11 OTHER E ;COST '. '. . . 0 I,,.,, ". ""''''"'' , COST' F 267 255, 72 592 2,6,631 AIDS ARMS, INC, 351 WEST JEFFERSON BLVD SUITE 300 DALLAS TX 75208-4599 DETAILED LINE ITEM BUDGET FOR INDIRECT COST AGENCY: AIDS ARMS, INC, GRANT:Ryan White Part A Formula SERVICE CATEGORY: Local AIDS Pharmaceutical Assistance GRANT PERIOD: March 1, 2012 to February 28, 2013 A 1 ;Sherrie, 2 I Warren
5 ,John Carlo 6 i Moreno 7 'Vickie 8 7 8 9 ITURE ITEMS POSITION TITLE Lead A Staff Staff , ; .. 0 Chief Office Human I ,Officer Ii TOTAL ANNUAL SALARY B 663 320 000 98,536 140,000
63,000 % ,Bdgtd, C 5 5 4' 3% 2% 10% 4% D 1,000 780 780 2,670 2,670 2,670 2,670 10 !11_ ""', ><" ',', ' ,,'" ,"" ", < > "", ',' 14 ravel Iii 111 il l' 1: Other 1: 21 I OTHER E 24
" 25 L'j .cu:;. , ' , """ ',' , * NOTE: Total indirect cost cannot exceed 10% of the approved award for the service category. F - - - 725 1,700 2,425 23,317 312,518 AIDS ARMS, INC. 351 WEST JEFFERSON BLVD SUITE 300 DALLAS TX 75208-4599 FEIN: 75-2306145 AIDS Arms, Inc. EXHIBIT A-3 (a) FY 2012- 2013 Ryan White Part A Formula Grant Service Category -Local AIDS Pharmaceutical Assistance I. A Benefits Coordinator - Carletta Simpson. Peabody Health Center'. Assesses all patients for eligibility of third party payors and the PHC drug reimbursement program. Completes and maintains all necessary documentation for application and ongoing reassessment of eligibility. Annual Salary B 36,504 20% 7,120 Benefits Coordinator - Krist! Thomas Trinity Health & Well ness Center: Assesses all patients of PHC for ellgibility of third party payers and the THWC drug reimbursement program. Completes and maintains all necessary documentation for application and ongoing reassessment of eligibility. Annual Salary C 35,090 Director of Clinic Administration Nicole Wilbur: 20% 7,120 Supervises and provides guidance to benefits coordinator. Reviews eligibility documentation periodically to ensure procedures are consistently followed. Annual Salary D Data Support Speclallst Angle Ibarra: 55,000 10% 5,340 Ensures functionality of source document flow through out the agency. Enters programmatic and client information into ARIES from the common intake form. Enters service delivery information into ARIES from daily drug log sheets from Bioscrip. Annual Salary E 29,390 Technology and Data Manager - Rick Funches: 21% Ensures and manages functionality of information technology systems, including new user set up, e-mai! set up and configuration, and hardware and software configuration and installation for direct client service staff. Completes all software updates In charge of new telephone user and voice mail set up for direct client service staff. Annual Salary II. FRINGE BENEFITS 1M' \to 65,000 FICA Unemployment Employee Health and Dental Retirement Disability Insurance Life Insurance Expense Workers' Compensation 1'Ipnel<equested 2% Office and computer supplies necessary for staff to provide services to clients as funded by this grant. 22.25 per month 7.65% 0.98% 9.54% 1.27% 0.71% 0.55% 0.48% 21.18% 12 months 6,230 1,068 2,056 263 2,564 341 191 148 129 5,692 267 2.;87:8 5,692 AIDS ARMS, INC. 351 WEST JEFFERSON BLVD SUITE 300 DALLAS TX 75208-4599 FEIN: 75-2306145 AIDS Arms, Inc. EXHIBIT A-3 (a) FY 2012 2013 Ryan White Part A Formula Grant Service Category -Local AI DS Pharmaceutical Assistance
I. Pharmacy: Contract for the dispensing of medications. Name of Subcontractor: Avita Drugs, LLC. Amount of Contract: 629,464 41% 255,672 Method of Selection: Sole Source Period of Performance: March 1, 2012- February 28, 2013 Description of Services: Dispensing of all medically necessary prescriptions for patients who meet program guidelines. Payer of last resort after compassionate care, Medicaid and ADAP. Name of Subcontractor: 0.67% Amount of Contract: Bid / Interview Method of Selection: March 1, 2012-February 28, 2013 Period of Performance: Description of Services: Consulting, network support, and programming needs beyond the competence of current IT staff.
A Communications Telephone and internet access to provide cllent service. B Insurance Genera! liability insurance, including insurance coverage for property and equipment and professional liability insurance coverage for service staff. C Equipment Lease/Rental Portion of copier and telephone lease D Building Maintenance and repair Portion of the building maintenance and repair cost allocated to the grant E Copying and Printing Outside printing of letterhead, appointment cards, and business cards, and cost for copier overage. F Security Portion of the security cost allocated to the grant. VIII. TOTAL DIRECT COSTS IX. PROGRAM INCOME We are projecting $100,000 progrram income from the 340B Modified program, X. THIRD PARTY REIMBURSEMENTS Not Applicable The Benefits coordinator assessed aU clients for eligibility of Medicaid, Medicare, and private insurance. Only services provided to clients who don't qualify for third party reimbursement are billed to Ryan White, 100 89 67 80 178 45 133 255,7,1.2' 592' AIDS ARMS, INC. 351 WEST JEFFERSON BLVD SUITE 300 DALLAS TX 75208-4599 FEIN: 75-2306145 AIDS Arms, Inc. EXHIBIT A-3 (b) FY 2012- 2013 Ryan White Part A Formula Grant Service Category -Local AIDS Pharmaceutical Assistance I. INDIRECT PERSONNEL A Lead Accountant - Sherrie Jackson: Reviews payroll before it is submitted for processing. Prepares financial statements and billings for all grant funded activities. Assists CFO with other accounting and reporting activities. Annual Salary 59,663 5% B Staff Accountant - Chakara Warren 3,000 Prepares payroll documents for processing, including benefits and deductions. Assists Lead Accountant with other accounting duties. Annual Salary C 34,320 Staff Accountant- General Laffitte: 5% Processes AlP and AIR. Assists Lead Accountant with other accounting duties. Annual Salary D 40,000 4% 1,780 1,780 Chief Financial Officer - Gilbert Kouame: Ensures accurate and timely financial reporting and audit activities. Insures compliance with all financial requirements of funders, government and the Board. Supervises staff accountant and IT staff. Provides financial strategic planning. Annual Salary E 98,536 3% 2,670 Chief Executive Officer-John Carlo: Responsible for all administrative and programmatic activities of the agency. Provides direct supervision of all management personnel. Ensures compliance with all contracts and financial functions. Annual Salary F 140,000 2% 2,670 Office Support Specialist -Anayeici Moreno Provides phone coverage and administrative support to management. Coordinates client and provider requests for appointments information for AAI Sunset location. Annual Salary G 27,373 10% Human Resource Manager - Vickie Johnson: Administers agency's benefit programs. 2,670 Ensures compliance with labor laws and regulations, and coordinates staff development activities. Annual Salary 63,000 4% 2,670 II. FRINGE BENEFITS FICA 7.65% 1,319 Unemployment 0.98% 169 Employee Health and Dental 9.54% 1,645 17,240 3,652 AIDS ARMS, INC. 351 WEST JEFFERSON BLVD SUITE 300 DALLAS TX 75208-4599 FEIN: 75-2306145 AIDS Arms, Inc. EXHIBIT A-3 (b) FY 2012- 2013 Ryan White Part A Formula Grant Service Category -Local AIDS Pharmaceutical Assistance Retirement 1.27% 219 Disability Insurance 0.71% 122 Life Insurance Expense 0.55% 95 Workers' Compensation 0.48% 83 21.18% 3,652 III. STAFF TRAVEL IV. EQUIPMENT V. SUPPLIES VI. CONTRACTUAL A None Requested None Requested None Requested Name of Subcontractor: Srosowske, Mares, Smothermon & Co., P.C Amount of Contract: 16,000 4% Method of Selection: Period of Performance: Description of Services: B Bid / Interview March 1, 2012 - February 28, 2013 Performs Single Audit Name of Subcontractor: Avior Innovations Amount of Contract: 2,000 Method of Selection: Bid / Interview Period of Performance: March 1, 2012 - February 28, 2013 3% Description of Services: Provides support for the accounting software (MIP) C Name of Subcontractor: Amount of Contract: Method of Selection: Period of Performance: Description of Services: Custom Payroll Assoicates, CPA 7,000 Bid / Interview March 1,2012 - February 28,2013 VII. OTHER INDIRECT COSTS A Communications Telephone and internet access for administrative staff. S Insurance 0.6% Directors and Officers liabilty insurance and fidelity bond allocated to the grant. C Equipment Lease/Rental Portion of copier and telephone lease allocated to administrative staff D Occupancy Portion of the occupancy cost allocated to the grant. VIII. TOTAL INDIRECT COSTS 623 57 45 15 15 15 1,655 725 1,700 23,317 AIDS ARMS, INC, 351 W. JEFFERSON BLVD SUITE 300 DALLAS TX 75208-4599 FEIN: 752306145 EXHIBIT B1: PERFORMANCE OBJECTIVE FORM I I AIDS, 1 BLVD. S,ite 300 . Ry," Progcam Part A IIPHONE II OBJEC , vouc' I , If thece .ce problem "eas. descc'be youc pia" 10 ,,'ve ate. Service Category and Performance Amount Unttof Annual Target Completion Dates and M"suce Goal clthec PI,"s, 0 , , Total'E Peeso" ,
Wome" Pmo" " Pecso" , I , Pees" , , Seeved '"'a"ts Peeso" Pecso, I i Medical Care 1$ 1 Dotes U,it Cost I 1,396.74 II 2128/2013 II , ".",to,,, 5, )76 Peeso"s Seeved I 'ecso" I.t'! ;.. . . . Locat AIDS I AsslSta" IS T"get' 1 Dotes 828.96
212812013 Peeso"s leeved I ,Is Pecso, 0 " ' .. . AIDS ARMS, INC. 351 W. JEFFERSON BLVD SUITE 300 DALLAS TX 75208-4599 FEIN: 75-2306145 FY 2012-2013 Ryan White Title Part A, B, & DSHS AGENCY:AIDS Arms, Inc. 351 W. Jefferson BLVD, Suite 300 Dallas, Texas 75208-4599 EIN: 75-2306145 I # I!OTAl LINE IrEM COS 6 8 172 L1 119 120 124
I1ll P I (Direct) Fringe (Direct) Travel (Direct) (Direct) Direct) _([)irecJl Other (Direct) Total Direct Total Indirect - ----_ .. _---- ----- Part A Formula 454 783 014 --0 46,07: 47,088 1,446,97: 148,21: EXHIBIT C1: MULTIPLE FUNDING SOURCE FORM % OF TOTAL BUDGET FUNDED BY RYAN WHITE PART A, B & DSHS: % OF TOTAL BUDGET FUNDED BY Ryan White Part A Formula: % OF TOTAL BUDGET FUNDED BY Ryan White Part A Supplemental: % OF TOTAL BUDGET FUNDED BY Ryan White Part B : % OF TOTAL BUDGET FUNDED BY Ryan White Part A MAl: % OF TOTAL BUDGET FUNDED BY DSHS: DALLAS COUNTY PASS TI Part A Part B Supplemental Formula C IDE 329,978 3' 69,888 67 4,920 5,4 o - 27,087 12,120.0( 260,526 202,129.0( 14,237 17,357.0( 706,636 621,509,0( 70,636 64,1 OO.O( Part A MAl 352,934 4,753 4,435 o 8,625 360,692 11,748 813,187 70,345 DSHS G 121,25' 25,682 14,019 o 9,33, 50( 4,637 175,428 19,20C 45.12% 17.40% 8.48% 7.48% 9.64% 2.12% OTHER OTHER FEDERAU LOCAL STATE PRIVATE H 96, 79,1271-3; 58,1961 9,03: 6,964 63,668 2,714,097 INCOME J 17,295 3,829 50,000 4,000 75,124 24,8: TOTAL FUNDING SOURCES K 116,867 50,000 170,465 1 ,607,907 1,473,72: 771;272 ::.S85,P!!,:;,,J!83,93l).; v': ::19:'1,g282;924;;'I,@::g;QoSi EXHIBIT C2: ALLOCATION FORM AGENCY: AIDS Arms, Inc 351 W. Jefferson, Suite 300 Dallas, Texas 75208
(Direct and Indirect Combined)
I , , . II , II , Iii ill FY 2012-2013 Ryan White Part A, Band DSHS EIN: 752306145 , , INCOME (%j SOURCES
DALLAS COUNTY HEALTH AND HUMAN SERVICES GRANTS MANAGEMENT ZACHARY THOMPSON DIRECTOR TO: Zachary Thompson, Director FROM: Anrelio Rodriguez, Grants Management Officer DATE: February 12,2013 SUBJECT: FY 2012 - 2013 Part A Formula Budget CONTRACTOR NAME: Dallas County Hospital District GRANT PROGRAM: FY 2012 - 2013 Part A Formula Budget The attached contract was reviewed by Grants Management staff and is ready for signature. The following items were verified: ITEM 1. 2. o J. Amount corresponds with Briefing and Court Order documents. All five originals signed by appropriate agent of organization. Budget Exhibits A are calculated correctly. 4. Performance Objectives, Exhibit B-1, contains appropriate units of service. ~ ~ . 5. Multiple Funding Sources, Exhibit C, contains updated funding information. - ~ 6. All budget forms appropriately entitled with agency name, address, and ~ _ II\. I federal ID number. ~ ~ 2377 Stemmons Freeway Suite 200 LB-16 Dallas, Texas 75207-2710 Office (214) 819-1842 FAX (214) R19-liO?'1 \0 CONTRACT FOR HIV/AIDS SERVICES DELIVERY FUNDED UNDER THE FY 2012 TITLE XXVI OF TIlE PHS ACT, AS AMENDED BY THE RYAN WHITE HIV/AIDS TREATMENT EXTENSION ACT OF 2009: PART A FORMULA FUNDING GRANT CATALOG OF FEDERAL DOMESTIC ASSISTANCE (CDFA) NO. 93.914 Between DALLAS COUNTY HEALTH & HUMAN SERVICES (Contractor) and Dallas Connty Hospital District d.b.a. Parkland Healtb and Hospital System (Sub-Contractor) I. PURPOSE: Contract Amendment No, 3 amends the HIV/AIDS Services Delivery Fnnded under the FY 2012 Title XXVI of the PHS Act, as amended by the Ryan White HIV I AIDS Treatment Extension Act of2009: Part A Formula grant agreement executed between Dallas County Health & Human Services and Parkland Health and Hospital System, effective March 23, 2012, n. AMENDED PROVISIONS: Contract Amendment No, 3 shall not change any contractual provisions agreed upon in the Ryan White HIV/AIDS Treatment Extension Act Part A Formula funded agreement; each provision shall remain in effect throughont the term of the agreement with the exception of the following amended provisions: A: AMENDED CONTRACT AMOUNT: The contract payment provisions are revised to increase funds in the amount of $51,378 in AIDS Pharmaceutical Assistance, $89,125 in Case Management, and $164,619 in Ambulatory/Outpatient Medical Care, The total contract is increased to $2,774,525, Original Part A Formula grant contract amount: Award due to Amendment No, 1: Award due to Amendment No, 2: Award due to Amendment No, 3: Total amended contract amount: $2,302,516.00 $ 25,074.00 $ 141,813.00 $ 305,122.00 $2,774,525.00 For: B: AMENDED PROVISIONS: The revised Exhibit A-I (detailed for the line item service budget), A-3 (budget justification), B-1 (performance objectives), and CI and C2 (multiple funding sources) reflect increased funding in the AIDS Pharmaceutical Assistance, Case Management and Ambulatory/Outpatient Medical Care service categories. C. TERM: Contract Amendment No.3 shall not affect the original term of the contact that is in effectthrough Febl1lary 28, 2013. Parkland Health and Hospital System Walter Shaw __________ _ (Print or type name) Interim EVP and CFO Print or type Title L/""2>'--____ _ For: Dallas County Date Clay Lewis Jenkins Dallas County Judge Date: ___________ _ EXHIBIT A-I (a): DETAILED LINE ITEM BUDGET FOR DIRECT COST AGENCY: Dallas County Hospital District EIN:7S-6004221 GRANT: Ryan White Part A Formula Amend. #3 5201 Harry Hines Blvd., Dallas, Texas 75235-7793 SERVICE CATEGORY:AIDS Pharmaceutical Assistance GRANT PERIOD: 03/23/2012 - 02128/2013 AL ANNUAL POSITION SALARY Dallas County Hospital District dba Parkland Hearth Hospital System c"v ')('14') OIM D"rl A e ..... """"I" /lIne Dh ................... ""f, ....... 1 " ... ,,; ... f ... ~ ........ I \ ~ ... n...i -Ii'} EXIDBIT A-I (b): DETAILED LINE ITEM BUDGET FOR INDIRECT COST AGENCY: Dallas County Hospital District EIN:75-6004221 5201 Harry Hines Blvd., Dallas, Texas 75235-7793 SERVICE CATEGORY:AIDS Pharmaceutical Assistance GRANT: Rvan White Part A Formula Amend. #3 GRANT PERIOD: 0312312012 - 0212812013 ALLOCATED "NOTE: Total indirect cost cannot exceed 10% of the approved award for the service category, Dallas County Hospital District dba Parkland Health Hospital System FY 2012 RW Part A Formula - AIDS Pharmaceutical Assistance Amend. #3 DIRECT PERSONNEL DALLAS COUNTY HOSPITAL DISTRICT DBA/Parkland Health & Hospital System 5201 Harry Hines Boulevard Dallas, Texas 75235-7793 EIN: 75-6004221 BUDGET JUSTIFICATION FOR DIRECT COSTS EXHIBIT A-3 (a) FY 2012 - 2013 Ryan White Part A Formula Amend. #3 AIDS PHARMACEUTICAL ASSISTANCE No Funds requested during this grant cycle. II FRINGE BENEFITS No Funds requested during this grant cycle. III TRAVEL No Funds requested during this grant cycle. IV EQUIPMENT No Funds requested during this grant cycle. V SUPPLIES No Funds requested during this grant cycle. VI CONTRACTUAL No Funds requested during this grant cycle. VII OTHER DIRECT COSTS Outpatient Medication Therapy: Medications that will improve the quality of life for the PLWH/A population serviced by Dallas County Hospital District. VIII TOTAL DIRECT COSTS IX PROGRAM INCOME No program income will be generated for this service category. $ $ $ $ $ $ $ $ $ X THIRD-PARTY REIMBURSEMENTS $ All clients are screened at intake and re-assessed every six (6) months for eligibility and the potential for collection of third party reimbursements. All third party reimbursement sources are utilized first before Ryan White Funds are made available, making Ryan White funds the Payor of Last Resort. All third party reimbursements are tracked separately. Dallas County Hospital District dba Parkland Health Hospital System !="y ?n1? RW P::ui A Fnrmlll::! - ArnS Al':!';i!';tRnr.p. Aml'mrl 441,093.00 441,093.00 DALLAS COUNTY HOSPITAL DISTRICT DBA/Parkland Health & Hospital System 5201 Harry Hines Boulevard Dallas, Texas 75235-7793 EIN: 75-6004221 BUDGET JUSTIFICATION FOR INDIRECT COSTS Exhibit A-3 (b) FY 2012 - 2013 Ryan White Part A Formula Amend. #3 AIDS PHARMACEUTICAL ASSISTANCE INDIRECT PERSONNEL No Funds requested during this grant cycle. II FRINGE BENEFITS No Funds requested during this grant cycle. III TRAVEL No Funds requested during this grant cycle. IV EQUIPMENT No Funds requested during this grant cycle. V SUPPLIES No Funds requested during this grant cycle. VI CONTRACTUAL No Funds requested during this grant cycle. VII OTHER INDIRECT COSTS Dallas County Hospital District has an approved Indirect Cost Rate of 23.4% (see attachment), we are requesting the 10% maximum authorized by Ryan White Legislation. VIII TOTAL INDIRECT COSTS Dallas County Hospital District dba Parkland Health Hospital System FY 2012 RW Part A Formula - AIDS Pharmaceutical Assistance Amend. #3 $ $ $ $ $ $ $ $ $ $ $ $ 49,010 $ 49,010 $ 49,010 EXHIBIT A2: DETAILED FEE FOR SERVICE BUDGET AGENCY: Dallas County Hospital District EIN:756004221 5201 Harry Hines Blvd., Dallas, Texas 752357793 SERVICE CATEGORY: Outpatient/Ambulatory Medical Care 1. PROPOSED UNIT/UNITS OF SERVICE: Visits 2. NUMBER OF UNITS OF SERVICES TO BE PROVIDED: 3,857 3. TOTAL COST OF SERVICES: $1,619.736 4. PROPOSED UNIT COST FOR SERVICE: $420.00 5. BREAKDOWN OF TOTAL COSTS AND PROPOSED FEE FOR SERVICE: GRANT: FY 12 13 Ryan White Part A Fonn Amend. #3 GRANT PERIOD: 03/23/201203/31/2013 * NOTE: Total indirect cost cannot exceed 10% of the approved award for the service category. Dallas County Hospital District dba Parkland Health and Hospital System FY 2012 RW Part A Formula - O/AMC Amend. #3 DIRECT PERSONNEL DALLAS COUNTY HOSPITAL DISTRICT DBAIParkland Health & Hospital System 5201 Harry Hines Boulevard DaUas, Texas 75235-7793 EIN: 75-6004221 BUDGET JUSTIFICATION FOR DIRECT COSTS EXHIBIT A-3 (a) FY 2012 - 2013 Ryan White Part A Form Amend. #3 OUTPATIENT/AMBULATORY MEDICAL CARE A. Medical Assistant, (T. Bamett)(C. Parramore) (S. Copland)(VACANT)(A. Lara) (A. Jackson) (G. Hernandez) Annual Salaries"" $196,602 40% Job Duties: Assists clinical staff with patient care including vital signs and dressing changes. B. Clinic Staff Assistant, (L. Ayers)(C. McCoy)(S. Green)(C. McKinney)(V. Nunez)(C. Rodriguez)(H. Rodriguez) (1 Jackman)(W. Powers) Annual Salaries"" $286,415 39% Job Duties: Must be proficient with automated office equipment; will prioritize and transcribe physician orders; management of medical records and telephones. C. Physician Assistant,(c. Cole-Johnson) Annua! Salaries = $140,026 37% Job Duties: Performs patient services and treatments under the supervision of a physician; assesses health status of patients; formulates, initiates; and implements plan of care. D. Business Operations Supervisor, (M. Briones) Annual Salaries == $46,634 40% Job Duties: Directs duties of Clinic Staff Assistants. Must be proficient with automated office equipment, will prioritize and transcribe physician orders; management of medical records and telephone E. Dietician, (M. Medina) Annual Salaries "" $46,820 39% Job Duties: Provides nutrition counseling and diet instruction according to physician orders. F. AIDS Regisrrar,(W. Traylor)( R. Thompson)(G. Pedroza)(S. Contreras) Annual Salaries"" $170,040 38% Job Duties: Abstracts medical charts of HI V and AIDS patients treated at PHHS to ensure accurate grants management and reporting to funding sources. Provides support for ARIES operation, report generation and data entry. G. Departmental Systems Manager, (D.Olivarez) Annual Salaries = $99,195 40% Job Duties: Responsible for tbe overall information systems operations management in the HIV Department including database creation/implementation/maintenance, applications analysis, project management, and serving as a liaison between the department and the IT division in order to ensure optimal information systems for the a<;signed department H. Medication Access Specialist, (B. Love) (E. Aguilera) (Elsy Vielma) Annual Salaries"" $117,873 40% job Duties: Administers Department of State Health Services HIV medication program and phannaceutical drug assistance programs by assisting patients with completion of applications facilitating between DSHS and the patient to coordinate medical care and drug adherence. I. Associate Unit Manager, (E. Regala) Annual Salaries = $76,800 40% Job Duties: Registered Nurse will work among clinic staff and provide direct supervision to ensure tbat patient care is coordinated, comprehensive and cost effective. J. Nurse Practitioner,(VACANT)(M. Monastesse)(A. Vasireddy) Annual Salaries"" $321,193 40% Job Duties: Advance practice RN performs patient services and treatments under the supervision of a physician; assesses health status of patients; formulates, initiates; and implements plan of care. Dallas County Hospital District dba Parkland Hcaith and Hospital System FY 20!2 RW Part A Fonnula - QIAIvlC Amend. #3 Dallas County Hospital District dba Parkland Health a.nd Hospital System FY 2012 RW Part A Formula. - OIAMC Amend. #3 $ 1,214,673 $ 78,640 112,477 51,879 18,653 18,260 64,103 39,678 47,149 30,720 128,477 DIRECT PERSONNEL (con'td) DALLAS COUNTY UOSI'ITAL DISTR[CT DBA/ParkJand Health & Hospital System 5201 Harry Hines Boulevard Dallas, Texas E[N: 75-6004221 BUDGET JUSTIFICATION FOR DIRECT COSTS EXHIBIT A-3 (a) FY 2012 - 2013 Ryan White Part A Form Amend. #3 OUTPATIENT/AMBULATORY MEDICAL CARE K. Registered Nurse,(W. Milne)(Y. Murphy) (A Moore)(D. Peters)(T. Sullins)(M. Olivo)(M. D'Andrade) (A Williams) (VACANT) Annual Salaries"" $622,252 41% Job Duties: For advocacy; explains clinic services; facilitates management ofpaticnt concerns. Clinically responsibility for total nursing care of patients; assesses, plans, and evaluates patient needs, directs clinic staff, and teaches self-help measures. L. Amb. Clinical StaffPhannacist,(H. Ekpunobi) (P.T. Lam) Annual Salaries'" $233,147 40% Job Duties: Provides needed clinic medications; serves as an active member of the HIV Clinic Team, provides pharmaceutical consulting services for HIV patients. M. Staff Adult HIV Physician,(M. Akbar) (D. Morris-Harris)(E. Rahman)(R. Ghurani) Annual Salaries:= $718,800" 24% Job Duties: Provide medical care to DCHD HIV/AIDS patients; responsible for the longitudinal care of Monitor the care of patients which includes, quality improvement, database development, and mentoring ofHlV/AIDS care providers. N. Lead Registered Nurse, (c. Loreto) (M. Brown) Annual Salaries = $133,057 40% Job Duties: Responsible for lead capacity supervision of assigned nursing staff in order to ensure the provision of comprehensive health care for patients accessing COPC Health Centers. O. Radiology Technician,(V. Duke: Annual Salaries = $77 ,459 38% .Tob Duties: Performs general diagnostic radiological exams and basic phlebotomy functions, as credentialed. P. Phannacy Tech,(L Corpus) Annual Salaries"" $48,443 40% Job Duties: Prepares medications (inhalation/injectable) under the direct supervision ofphannacist. Merit Increases: Parkland employees historically receive merit raises at an average rate of 4%. Total salaries: $0.00/26 X .04 X 10"" $0.00 $ 255,124 93,259 174,2[9 53,223 29,435 19,377 so tActual base full time salaries are: Dr. Akbar ($212,784). Dr. Ghurani ($181,709), Dr. Morris-Harris ($218,046) and Dr. R.ahmann ($191,755); RW legislative salary limitation for Executive Level !I is $179,700; Parkland Health and Hospital System agrees to fund salaries in excess oftbe mandated cap. Il FR[NGE BENEFITS Insurance(MedicaIlLife) Socia! Security Retirement Workers Compensation 20.1% Others (Disability, Unemployment, Medicare, Life Insurance, and Supp. Ret.) III TRAVEL No Funds requested during this grant cycle. IV EQUIPMENT No Funds requested during this grant cycle. V SUPPLIES No Funds requested during this grant cycle. VI CONTRACTUAL No Funds requested during this grant cycle. VII OTHER DIRECT COSTS 11.0% 0% 3.0% 0.3% 5.8% A. Other Professional Services: Medical services provided to Ryan White eligible clients by Dallas County Hospital District which includes the Community Oriented Primary Care Clinics and the Speciality Clinics. These are for services other than the HN Clinics. VIII TOTAL DIRECT COSTS Dallas County Hospital Districl dba Parkland Health and Hospital System FY 2012 RW Part A Formula - O/AMC Amend #3 Dallas County Hospital District dba Parkland Health and Hospital Systefl"l FY 2012 RW Pari A Formula - OIAMC Amend. #3 133,614 36,440 3,644 70,451 244,149 $0 $ 1,458,622 IX PROGRAM INCOME DALLAS COUNTY HOSPITAL DISTRICT DBA/Parkland Health & Hospital System 5201 Harry Hines Boulevard Dallas, Texas 75235 M 7793 EIN: 75-6004221 BUDGET JUSTIFICATION FOR DIRECT COSTS EXHIBIT A-3 (a) FY 2012 - 2013 Ryan White Part A Form Amend. #3 OUTI'ATIENT/AMBULATORY MEDICAL CARE Dallas County Hospital District (HIV Clinics) charges a flat fee for services based on the following: No charges to persons with income less than or equal to one hundred percent (lOO%) of the U.S. Department of Health and Human Services Poverty Guidelines published annually in the Federal Register. Charges are assessed to persons with an income greater than one hundred percent (100%) of the Poverty Guidelines but less than three hundred percent (300%). This is based 011 gross individual/family income which is assessed at intake and fe-assessed every six (6) months, Individual/family annual aggregate fees will confoml to the limitation established in the table listed in this contract under "7. CONTRACTOR'S OBLIGATIONS: (I) Charges to Clients. The Dallas County Hospital District (HIV Clinic) has a policy of not denying anyone services based on their inability to pay a fee, Any income generated from fee coi!ectioll is used to provide HIV primary care services. X THIRD-PARTY REIMBURSEMENTS All client'! are screened at intake and r e ~ a s s e s s e d every six (6) months for eligibility and the potential for collection of third party reimbursements. All third party reimbursement sources are utilized first before Ryan White Funds are made available, making Ryan White funds the Payor of Last Resort. All third party reimbursements are tracked separately. Dallas County Hospital District dba Parkland Health and Hospita! System FY2012 RWPart A Formula - O/AMC Amend. #3 Dallas County Hospital District doa Parkland Health and Hospital System FY 2012 RW Part A Formula - O/AMC Amend. #3 $0 so II III IY V YI DALLAS COUNTY HOSPITAL DISTRICT DBAlParkland Health & Hospital System 5201 Harry Hines Boulevard Dallas, Texas 7 5 2 3 S ~ 7 7 9 3 EIN: 75-6004221 BUDGET JUSTIFICATION FOR INDIRECT COSTS. EXHIBIT A-3 (b) FY 2012- 2013 Ryan White Part A Form Amend. #3 OUTPATIENT/AMBULATORY MEDICAL CARE INDIRECT PERSONNEL A Performance Improvement Analayst, (VACANT) Annual Salaries = $80,454 19% Job Duties: Organizes and coordinates Quality Improvement activities and analyzes and develops reports to ensure compliance with regulatory standards. B. Sr. Grant Specialist cr. Stanfield) Annual Salaries"'" $67,600 30% Job Duties: Directs the management of all fiscal, administrative, monitoring and reporting activities. Prepares and submits financial spreadsheets and program management reports to appropriate departments. Assists in audits and the preparation of grant proposals. Furnishes technical guidance to help ensure we develop and maintain a cost-effective operation. C. Administrative Assistant, (S. Villanueva) Annual Salaries = $47,653 28% Job Duties: Manages administrative support functions for the HIV Department. Provides direct services to HIV adminstrative personnel. Organizes meetings, develops correspondence, maintains schedules and works on special projects. D. Development Associate, (N. Piel Brown) Annual Salaries = $71,677 13% Job Duties: Plans, writes, budgets and submits grant proposals for HIV/AlDS programs to federal, state, and local govemments, foundations and donors to provide optimal granl/donor source revenue that supports the missions, goals and objectives of PHHS and the HIV/AIDS area. Merit Increases: Parkland employees historically receive merit raises at an average rate 01'4%. Total salaries: $0.00/26 X .04 X 10 = $0.00 FRINGE BENEFITS 20.1% Insurance(MedicaI/Life) 11.0% Socia! Security 0% Retirement 3.0% Workers Compensation 0.3% Others (Disability, Unemployment, 5.8% Medicare, Life Insurance, and Supp. TRAVEL No Funds requested during this grant cycle. EQUIPMENT No Funds requested during this grant cycle. SUPPLIES No Funds requested during this grant cycle. CONTRACTUAL No Funds requested during this grant cycle. VII OTIfER INDIRECT COSTS Dallas County Hospital District has an approved Indirect Cost Rate of 23.4% (see attachment). This amount allows us to request up to the 10% maximum authorized by Ryan White Legislation. VIII TOTAL INDIRECT COSTS Dallas County Hospital District dba Parkland Health and Hospital System FY 2012 RW Part A Fonnllia - O/AMC Arnend.#3 Dallas County Hospital District dba Parkland Health and Hospftal System FY 2012 RW Part A Fonnula - OIAMC Amend. #3 $ 58,640 $ 15,206 20,280 13,478 9,676 $0 11,786 6,450 1,759 176 3,401 $ $ $ $ $ 90,488 $ 160,914 EXHIBIT A-I (a): DETAILED LINE ITEM BUDGET FOR DIRECT COST AGENCY: Dallas Countv Hospital District EIN:75-6004221 5201 Harry Hines Blvd., Dallas, Texas 75235-7793 SERVICE CATEGORY: Case Management (Non-Medical) TOTAL ANNUAL DaJJas County Hospita! District dba Parkland Health Hospital System FY 2012 RW Part A Formula - CMfNM Amend. #3 GRANT: FY 12 -13 Ryan White Part A Formula Amend. #3 GRANT PERIOD: 03/23/2012 - 02/28/2013 % Bdgtd. TOTAL AMOUNT from ALLOCATED EXIDBIT A-I (b): DETAILED LINE ITEM BUDGET FOR INDIRECT COST AGENCY: Dallas County Hospital District EIN:75-6004221 5201 Harry Hines Blvd., Dallas, Texas 75235-7793 SERVICE CATEGORY: Case Management (Non-MedicaI) POSITION TITLE GRANT: FY 12 ~ 13 Rvan White Part A Fonnula Amend. #3 GRANT PERIOD: 03/2312012 - 0212812013 * NOTE: Total indirect cost cannot exceed 10% of the approved award for the service category. Dallas County Hospital District dba Parkland Health Hospital System FY 2012 RW Part A Formula - CM/NM Amend. #3 DmEeT PERSONNEL DALLAS COUNTY HOSPITAL DISTRICT DBAlParldand Health & Hospital System 5201 Harry Hines Boulevard Dallas, Texas 75235-7793 EIN: 75-6004221 BUDGET JUSTIFICATION FOR DIRECT COSTS EXHIBIT A-3 (a) FY 2012 ~ 2013 Ryan White Part A Formula Amend. #3 CASE MANAGEMENT (Non-Medical) A MSW Case Manager, (L. Barnes), (E. Bockarie), (M.Gonnan), (J. Green) Cc. Martin) CW. Robinson) (0 Williams) (J. Wilson), (Annual Salaries"" $518,056), 26% Job Duties: Responsible for completing patient assessment based on targeted population and financial plan authorization, Estabiishes plan of care for identified patients. Implements plan of care based on patient assessment Promotes collaborative practice between the patient, family, and healthcare disciplines. Intervenes to optimize use of resources. Serves as a communication liaison with patient/family, significant otner. Evaluates and revises plan of care. Co-ordinates planning and completes documentation in the medical record. Collects outcome data, Participates in perfonnance improvement B. Client Advocate, (E. Trevino), Annual Sa)ary = $ 44,886 37% Job Duties: Responsible for conducting intake, screening, and triage at point of entry for Initia Service Visit (ISV) and Walk-in patients. S134,376 $16,797 C. MSW Program Manager, (A. DeLa Rosa), Annual Salary "" $ 74,173 23% S16,797 Job Duties: Responsible for providing quality control for case managerment (non-medical) services. Also assist with completing patient assesments based on targeted population and financial plan authorization. Establishes plan of care for identified $ 167,970 Implements plan of care based on patient assessment. Promotes collaborative practice between the patient, family, and healthcare disciplines. Intervenes to optimize use of resources. Serves as a communication liaison with patient/family, significant other. Evaluates and revises plan of care. Co-ordinates planning and completes documentation in the medical record. Collects outcome data_ Participates in performance improvement Merit Increases: Parkland employees historically receive merit raises at an average rate of 4% Total salaries: $0.00/26 X .04 X 10 = $0,00 II FRINGE BENKFlTS I nsurance(M edicaJlLife ) Social Security Retirement Workers Compensation 20.1% Others (Disability, Unemployment, Medicare, Life Insurance, and Supp. Ret.) III TRAVEL No Funds requested during this grant cycle. IV EQUIPMENT No Funds requested during this grant cycle V SUPPLIES No Funds requested during this grant cycle. VI CONTRACTUAL No Funds requested during this grant cycle VII OTHER DIRECT COSTS No Funds requested during this grant cycle VIn TOTAL DIRECT COSTS IX PROGRAM INCOME 11.0% 3.0% 0.3% 5.8% No program income will be generated for this service category, X THIRDPARTY REIMBURSEMENTS No third-party reimbursements generated for this service category, Dallas County Hospital District dba Parkland Health Hospital System FY 2012 RW Part A Formula - CM/NM Amend. #3 so $ 33,762 18,477 5,039 504 9.742 $ $ $ $ $ S 201,732 $ $ INDIRECT PERSONNEL DALLAS COUNTY HOSPITAL DISTRICT DBAlParldand Health & Hospital System 5201 Harry Hines Boulevard Dallas, Texas 75235R7793 EIN: 75-6004221 BUDGET JUSTIFICATION FOR INDIRECT COSTS EXHIBIT A-3 (b) FY 2012 - 2013 Ryan White Part A Formula Amend. #3 CASE MANAGEMENT (Non-Medical) A. RN Case Management Manager, (Vacant), Annual Salary = $93,600 20% Job Duties: Plans, organizes, develops and monitors all activities of the Case Management Program, including hiring orienting, conducting staff meetings and perfonning perfonnance improvement. Assists in the coordination of all health and human services and empowering families and clients to access appropriate healthRrelated resources. Ensures that all Case Managers (RN and MSW) individualize plan of service and coordinate activities within the program plan of service and coordinate activities within the program. Merit Increases: Parkland employees historically receive merit raises at an average rate of 4%. Total salaries: $0,00/26 X ,04 X 10 = $0.00 II FRINGE BENEFITS 20.1% Insurance(MedicallLife) Social Security Retirement 11.0% Workers Compensation Others (Disability, Unemployment, Medicare, Life Insurance, and Supp. Ret.) III TRAVEL No Funds requested during this grant cycle. IV EQUIPMENT No Funds requested during this grant cycle. V SUPPLIES No Funds requested during this grant cycle. VI CONTRACTUAL No Funds requested during this grant cycle. VI OTIIER INDIRECT COSTS No Funds requested during this grant cycle. VI TOTAL INDIRECT COSTS Dallas County Hospital District dba Parkland Health Hospital System FY 2012 RW Part A Formula" CM/NM Amend. #3 3,0% 0.3% 5.8% $ 18,661 S 18,661 $0 $ 3,751 2,053 560 56 1,082 $ $ $ $ $ $ 22,412 5201 Harry Hines Blvd I ,Texas 752357793 PERFORMANCE OBJECTIVE FORM EXHIBIT 81 Dallas County Hospital District dba Parkland Health & Hospital System FY 2012 RW Part A Formula Amend. #3 Target Completion Dates and Other PERFORMANCE OBJECTIVE FORM EXHIBIT B-1 Dallas County Hospital District dba Parkland Health & Hospital System FY 2012 RW Part A Formula Amend. #3 Annual Target Completion Dates and Other I Comments EXHIBIT C-l : MULTIPLE FUNDING SOURCE FORM AGENCY: DALLAS COUNTY HOSPITAL DISTRICT ADDRESS: 5201 Harry Hines Blvd Dallas Texas 75235-7793 # TOTAL LINE ITEM COST RW Part A Formula Amend.#3 A B 1 Personnel $1,717,126 2 Frinqe Benefits $345,144 3 Travel 4 Eauioment 5 Supplies 6 Contractual 7 Other $441,093 % OF TOTAL BUDGET FUNDED BY (Part A Formula Amd#3): 27% % OF TOTAL BUDGET FUNDED BY (Part A Supplemental Amd.#2): % OF TOTAL BUDGET FUNDED BY (Part A MAl Amd.#1): % OF TOTAL BUDGET FUNDED BY (Part B): % OF TOTAL BUDGET FUNDED BY (State Services): FUNDING SOURCES 1:!% 0.3% 13% 1_2% DALLAS COUNTY PA::;S THROUGH GRANTS RW Part A RW Part A RW STATE DSHS OTHER Supplemental MAl Part 8 SRVCS. HOPWA FED. Amend.#2 Amend.#1 C D E F G H $779,765 $24,612 $927,336 $37,272 $1,758,855 $152,054 $5,538 $208,651 $8,386 $397,258 $1,010 $15,857 $25,467 $184,910 $28,577 $68,067 $10,693 OTHER GRANTS OTHER OTHER STATE LOCAU PRIVATE I J $223,970 $ 1,596,150 $51,513 $ 416,151 $115,962 8 : . 877J!-iI'.i$l!'ll'llI'lll1 i 9 10 11 12 13 14 15 16 17 18 19 20 21 Indirect Costs $271,162 $120,935 $3,350 Dallas County Hospital District dba Parkland Health & Hospital System FY 2012 RW Programs $121,937 $12,636 $155,712 $28,555 PROGRAM TOTAL INCOME FUNDING SOURCES K L $ 7,065,086 $ 1,584,695 $ 1,010 $ - $ 131,819 $ 25,467 $ 733,340
$ 714,287 I EXHIBIT C-2: ALLOCATION fORM AGENCY: DALLAS COUNTY HOSPITAl PISTRICT ADDRESS: 5201 Harry Hines BNd Danas. Texas 75235-7793 (Direct and indirect Combined) DeUas County Hospital District dDa Parkland Heatlh & Hospital System FY 2012 RW Programs E I N : ~ (%) INCOME ("10) Page 2 of 3 EXHIBIT C_2: ALLOCATION FORM AGENCY; QAt! AS COUNTI HOSPITAl DISTRICT ADDRESS: 52Q1 Hany Hines BM:! Dallas. Texas (Direct and Indirect Combined) Admll1 Dallas County Hospital District dba Parkland Health & Hospital System FY 2012 RW Programs EXPENSE MAl (%)