STATE OF HAWAII SUPPLEMENTAL CONTRACT NO. 1 TO CONTRACT DHS-08-MQD-5129 (Insert contract number or other identifying information)
Xxxxxxx 00.0
XXXXX
XX XXXXXX
SUPPLEMENTAL CONTRACT NO. 1
TO CONTRACT DHS-08-MQD-5129
(Insert contract
number or other identifying information)
This Supplemental Contract No. 1 , executed on the respective dates
indicated
below, is effective as of May
15 ,
2008
, between the
Department of Human
Services/Med-QUEST
Division
, State of
Hawaii
(Insert name of state
department, agency, board or commission)
("STATE"), by its Director,
Xxxxxxx X.
Xxxxxx,
(Insert
title of state officer executing contract)
(hereafter
also referred to as the HEAD OF THE PURCHASING AGENCY or designee ("HOPA")),
whose
address is 0000
Xxxxxx Xxxxxx, Xxxxxxxx, Xxxxxx
00000 ,
and
WellCare Health Insurance of
Arizona, Inc. dba
'Ohana ("CONTRACTOR"),
a Corporation
(Insert
corporation, partnership, joint venture, sole proprietorship, or other legal
form of the CONTRACTOR)
under the
laws of the State of Arizona ,
whose business address and federal
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and
state taxpayer identification numbers are as
follows: 0000 Xxxxxxxxx Xx.,
Xxxxx, XX
00000
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RECITALS
A. WHEREAS,
the STATE and the CONTRACTOR entered into Contract
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DHS-08-MQD-5129
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(Insert
contract number or other identifying information)
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dated
February
4 , 2008 , which
was amended by Supplemental Contract No(s). ___________ n/a
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dated __________ ____ ,
which was amended by Supplemental Contract No(s).
___________ n/a
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dated __________ ____ , which
was amended by Supplemental Contract No(s). ___________ n/a
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dated __________
____, (hereafter collectively referred to as "Contract") whereby the
CONTRACTOR agreed to provide the goods or services, or both, described in
the Contract; and
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B. WHEREAS, the parties now desire to amend
the Contract.
NOW,
THEREFORE, the STATE and the CONTRACTOR mutually agree to amend the Contract as
follows: (Check Applicable box(es))
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□
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Amend
the SCOPE OF SERVICES according to the terms set forth in Attachment-S 1,
which is made a part of the
Contract.
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□
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Amend
the COMPENSATION AND PAYMENT SCHEDULE according to the terms set forth in
Attachment-S2, which is made a part of the
Contract.
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□
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Amend
the TIME OF PERFORMANCE according to the terms set forth in Attachment-S3,
which is made a part of the
Contract.
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□
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Amend
the SPECIAL CONDITIONS according to the terms set forth in Attachment-S6
SUPPLEMENTAL SPECIAL CONDITIONS, which is made a part of the
Contract.
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x
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Recognize the CONTRACTOR'S change of name. |
| From: | 'Ohana Health Plan, Inc. | |
| _________________________________ | ||
| _________________________________ | ||
| _________________________________ |
AG-005 Rev
04/30/2007
1
| To: | WellCare Health Insurance of Arizona, Inc. | |
| dba 'Ohana Health Plan, Inc. | ||
| ________________________________ | ||
| ________________________________ | ||
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As
set forth in the documents attached hereto as Exhibit A , and
incorporated herein.
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A tax clearance certificate from the State of
Hawaii x
is o is not required to be
submitted to the STATE prior to commencing any performance under this
Supplemental Contract.
A tax clearance certificate from the Internal Revenue
Service x
is o is
not required to be submitted to the STATE prior to commencing any performance
under this Supplemental Contract.
The
entire Contract, as amended herein, shall remain in full force and
effect.
IN
VIEW OF THE ABOVE, the parties execute this Contract by their signatures, on the
dates below, to be effective as of the date first above
written.
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STATE
/s/ Xxxxxxx X.
Xxxxxx
(Signature)
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Xxxxxxx
X.
Xxxxxx
(Print
Name)
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Director
(Print
Title)
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01/14/09
(Date)
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CORPORATE
SEAL
(If
available)
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CONTRACTOR
WellCare
Health Insurance of Arizona,
Inc.
dba
‘Ohana Health Plan,
Inc.
(Name of
Contractor)
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/s/
Xxxxx
Xxxxxxxxx
(Signature)
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Xxxxx
Xxxxxxxxx
(Print
Name)
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President
and
CEO
*
(Print
Title)
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12-10-08
(Date)
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APPROVED
AS TO FORM:
/s/ Name
Illegible
Deputy
Attorney General
*
Evidence
of authority of the CONTRACTOR'S representative to sign this Contract for the
CONTRACTOR must be attached.
AG-005 Rev
04/30/2007
2
CONTRACT
NO. DHS – 08 – MQD -
5129
PROVIDER’S
ACKNOWLEDGMENT
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STATE
OF
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FLORIDA
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)
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COUNTY
OF
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HILLSBOROUGH
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)
ss.
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On this 10th
day of December, 2008, before me
appeared Xxxxx Xxxxxxxxx and ___________, to me known, to be the person(s)
described in and, who, being by me duly sworn, did say that he/she/they is/are the President and CEO
and __________ of Wellcare Health Insurance of
Arizona, Inc. dba ‘Ohana Health Plan, Inc. the PROVIDER named in the
foregoing instrument, and that he/she/they is/are
authorized to sign said instrument on behalf of the PROVIDER, and acknowledges
that he/she/they executed said
instrument as the free act and deed of the PROVIDER.
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(Notary
Seal)
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By /s/ Xxxxxxxx
XxXxxxx
(Signature)
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Print
Name Xxxxxxxx
XxXxxxx
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Date
________________________________
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Notary
Public, State of Florida
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My
Commission expires: February 14,
2010
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Doc.
Date:
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# Pages:
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________________ | ||
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Notary
Name:
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Circuit
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||||
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Doc
Description:
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(Notary
Stamp or Seal)
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_____________________________________________________
Notary
Signature Date
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NOTARY
CERTIFICATION
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AG Form
l03F( 10/08)
CONTRACT
NO. DHS –
08-MQD-5129
PROVIDERS
STANDARDS
OF CONDUCT DECLARATION
For the
purposes of this declaration:
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"Agency"
means and includes the State, the legislature and its committees, all
executive departments, boards, commissions, committees, bureaus, offices;
and all independent commissions and other establishments of the state
government but excluding the
courts.
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"Controlling
interest" means an interest in a business or other undertaking which is
sufficient in fact to control, whether the interest is greater or less
than fifty per cent (50%).
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"Employee"
means any nominated, appointed, or elected officer or employee of the
State, including members of boards, commissions, and committees, and
employees under contract to the State or of the constitutional convention,
but excluding legislators, delegates to the constitutional convention,
justices, and judges. (Section 84-3,
HRS).
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On behalf
of:
WellCare Health Insurance of
Arizona, Inc., dba 'Ohana Health Plan,
Inc.
(Name
of Provider)
PROVIDER,
the undersigned does declare as follows:
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1.
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PROVIDER ¨ is* x is
not a legislator or an employee or a business in which a legislator or an
employee has a controlling interest. (Section 84-15(a),
HRS).
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2.
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PROVIDER
has not been represented or assisted personally in the matter by an
individual who has been an employee of the agency awarding this Contract
within the preceding two years and who participated while so employed in
the matter with which the Contract is directly concerned. (Section
84-15(b), HRS).
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3.
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PROVIDER
has not been assisted or represented by a legislator or employee for a fee
or other compensation to obtain this Contract and will not be assisted or
represented by a legislator or employee for a fee or other compensation in
the performance of this Contract, if the legislator or employee had been
involved in the development or award of the Contract. (Section 84-14 (d),
HRS).
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4.
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PROVIDER
has not been represented on matters related to this Contract, for a fee or
other consideration by an individual who, within the past twelve (12)
months, has been an agency employee, or in the case of the Legislature, a
legislator, and participated while an employee or legislator on matters
related to this Contract. (Sections 84-18(b) and (c),
HRS).
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PROVIDER
understands that the Contract to which this document is attached is voidable on
behalf of the STATE if this Contract was entered into in violation of any
provision of chapter 84, Hawai'i Revised Statutes, commonly referred to as the
Code of Ethics, including the provisions which are the source of the
declarations above. Additionally, any fee, compensation, gift, or profit
received by any person as a result of a violation of the Code of Ethics may be
recovered by the STATE.
____________________________
* Reminder to agency:
If the "is" block is checked and if the Contract involves goods or services of a
value in excess of $10,000, the Contract may not be awarded unless the agency
posts a notice of its intent to award it and files a copy of the notice with the
State Ethics Commission. (Section 84-15(a), HRS).
AG Form
103F (10/08)
Standards
of Conduct Declaration
Page 1 of
2
CONTRACT NO. DHS –
08-MQD-5129
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PROVIDER
By /s/ Xxxxx
Xxxxxxxxx
(Signature)
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Print
Name Xxxxx
Xxxxxxxxx
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Print
Title President
and CEO
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Date
12-10-08
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AG Form
103F (10/08)
Standards
of Conduct Declaration
Page 2 of 2
CONTRACTNO. DHS –
08-MQD-5129
CERTIFICATE
OF EXEMPTION FROM CIVIL SERVICE
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1.
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By
Heads of Departments or Agencies as Delegated by the Director of Human
Resources Development1.
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Pursuant to the delegation of the
authority by the Director of Human Resources Development, I certify that the
services provided under this Contract, and the person(s) providing the services
under this Contract are exempt from the civil service, pursuant to §76-16,
Hawai'i Revised Statutes ("HRS").
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/s/
Xxxxxxx X.
Xxxxxx
(Signature)
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01/14/09
(Date)
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Xxxxxxx
X.
Xxxxxx
(Print
Name)
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Director
of Human
Services
(Print
Title)
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______________________________
1 This
part of the form may be used by all department heads and others to whom the
Director of Human Resources Development (DHRD) has delegated authority to
certify §76-16, HRS, civil service exemptions. The specific paragraph(s) of
§76-16, HRS, upon which an exemption is based should be noted in the contract
file. NOTE: Authority to certify
exemptions under §§ 76-16(2), 76-16(12), and 76-16(15), HRS, has not been
delegated; only the Director of DHRD may certify §§76-16(2), 76-16(12), and
76-16(15) exemptions.
2. By
the Director of Human Resources Development, State of
Hawai'i.
I certify
that the services to be provided under this Contract, and the person(s)
providing the services under this Contract are exempt from the civil service,
pursuant to §76-16, HRS.
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_______________________
(Signature)
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________________
(Date)
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_______________________
(Print
Name)
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_______________________
(Print Title, if
designee of the Director of
DHRD)
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AG
Form 103F (9/08)
Competitive
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Page
1
EXHIBIT
A
Department
of Commerce and
Consumer Affairs
CERRTIFICATE
OF MERGER
I, XXXXXXXX X. XXXXXXXX, Director of
Commerce and Consumer Affairs of the State of Hawaii, do hereby certify that
'OHANA HEALTH PLAN, INC., a Hawaii profit corporation has been merged with and
into WELLCARE HEALTH INSURANCE OF ARIZONA, INC., an Arizona profit corporation;
that the name of the surviving corporation is WELLCARE HEALTH INSURANCE OF
ARIZONA, INC.; that the Articles of Merger in conformity with Chapter 414,
Hawaii Revised Statutes, was filed in the Department of Commerce and Consumer
Affairs on May 14, 2008, and that the merger became effective on May 15, 2008,
at 12:01 a.m., Hawaiian Standard Time.
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IN
WITNESS WHEREOF, I have hereunto set my hand and affixed the seal of the
Department of Commerce and Consumer Affairs, at Honolulu, State of Hawaii,
this 16lh
day of May, 2008.
/s/
Xxxxxxxx X. Xxxxxxxx
Director
of Commerce and Consumer Affairs
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