ORDERNO, __________ _

DATE: FEBRUARY 26,2013
STATE OF TEXAS
COUNTY OF DALLAS
§ §
§ §
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 A·1 (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: 75·2306145
EXHIBIT B·1: 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 C·2: 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 A·2: DETAILED FEE FOR SERVICE BUDGET
AGENCY: Dallas County Hospital District EIN:75·6004221
5201 Harry Hines Blvd., Dallas, Texas 75235·7793
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: 03/23/2012·03/31/2013
* 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 THIRD·PARTY 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 75235·7793
PERFORMANCE OBJECTIVE FORM
EXHIBIT 8·1
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
(%)

(%) (%)
FUNDING
(%)
INCOME
(%)
Page 3 of 3

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