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Access Florida Community Network Agreement~cc~>- ,~ ~o~r ~~ CCESS Florida ACCESS Floritla Community Network Agreement (Replace with complete name of Oraanizationl located at, (replace with oraamization's site physical address ,agrees to serve as an access point for applicants and recipients of ACCESS Florida services. For purposes of this agreement ACCESS' Florida services are Food Stamps, Temporary Cash Assistance, Refugee Assistance, and Medicaid programs administered by the Department of Children and Families. As a member of the ACCESS Florida Community Network our organization will be available to: ^ Serve our current Giant population Serve the general public in our community. Our name and street address information as listed above may be advertised as an ACCESS Florida Community Network site and listed on the ACCESS Florida public Internet web page at http-Ilwww dcf state.fl.usless/. 6'~Yes ^ No If access to the Customer Look-up system is desired, we request the partner is listed on the ACCESS Community Network site. Our telephone number may be included with this advertisement. @j Yes ^ No Phone Number305-673-7691 All ACCESS Community Network Partners will display ACCESS signage, required informational posters and ACCESS brochures to support customer education and support and will notify the Department of any established partner site closures. ^ SetfService Site ~$~i-Assisted Service Site ^ Information Sits ServtceType:F~ood Stamps, Medicaid ~l Provide irrfortnational handouts Provide paper applications as requested by customers Provide access to telephone to call DCF Customer Call CenterlAutomated ACCESS Response Unk: 1-666-76ACCES / 1-666-762-2237 ~Rj Provide computer to apply for assistance on-line L~ Provide printer for ACCESS documents ~l Provide fax machine to fax application and other docunreMs to f7Cf `~ Provide copy machine to copy application related documents Provide ability to explain application process k Provide assistance to customers to submit their application, verification information and/or documentation Provide ability to assist customers to complete the ACCESS Florida Application f~( Provide case status information and outstanding information needed to determine eligibility. Automated Community Connection to Economic Self-Sufficiency COMMUNITY PARTNER ASSURANCES Civil Rights Compliance The Community Partner shall ensure that all civil rights requirements are met. All applicants and recipients are granted civil rights in accordance with Federal laws and US Department of Agdculture, Food and Nutrition Services (USDA) policy that services will be provided without discrimination on the basis of race, color, national origin: age. sex, disability, political beliefs or religion. The nondiscrimination poster, `And Justice for All", is posted on the ACCESS Florida internal page at htto !/www myflorida com/accessflorida/. If this web pays Is not accessible to customers, the "And Justice for All "poster shell be posted in a lobby area for customers to read. II only use confidential customer case file information to assist the applicant, the nt or their respective duly authorized representatives, with the completion of the ACCESS Florida benefits or services, conducting an Investigation info reement or the administration of ACCESS Florida programs. Community Partner dential customer case file information to the applicant, the recipient, or ~spective duly authorized representatives only for those purposes set forth in this Partner has questions or concerns about safeguarding of confidential case file ~ded use or disclosure of such information, Community Partner must contact the office Contact Person, or their designee. Community Partner agrees not to local DCF contact person within 48 Hours of the recerpr m veruai u~ wnuan nformation. No information obtained from a customer's records may be sharec anizations. All such requests should be refetted to DCF for review and aclion. Health Insurance Portability and Accountability Act Where applicable, community partners agree to comply with the Health Insurance Portability and Accountability Act (42 U. S. C. 1320d.) as well as all regulations promulgated thereunder (45 CFR Parts 160, 162, and 164). Brochures, ACCESS Materials and Signage Community Partner shall ensure that customers are aware that they are an ACCESS Partner by displaying an ACCESS Sign in their store front window or other appropriate area as agreed upon between the Department and the Communty Partner. Brochures, paper applications and other informational ACCESS materials shall be made available to customers. Training and Site Visks The Community Partner shall participate in training provided by Department in the following areas: (1) the use or disclosure of confdential case file information, incuding information governed by the Healtfi Insurance Portability and Accountability Act of 1996 and its implementing federal regulations; (2) the availability of public assistance benefits and services administered by Department; (3) the application process for public assistance programs; (4) Department's ACCESS Florida intiative and Community PartnePs role in the initiative, and (5) for those partners using the Customer Look-up System only, Department's Security Awareness training. The Community Partner agrees to on-site visits as established by the Department. Information Security Obligations ~ The Partner shall be held responsible for information security, especially involving the access, transport or storing of sensriive and confidential information. Futflllrnent of security responsibilities shall be mandatory and violations may be cause for action, up to and including civil penalties or criminal penalties under chapters 119, 812, 815, 817, 839; or 877, Floida Statutes, or similar laws. ' Client Risk Prevention and Incident Reporting The Community Partner must imrtrediately report knowledge or reasonable suspicion of abuse, neglect, or exploitation of a child, aged person, or disabled adult to the Florida Abuse Hotline on the statewide toll-free telephone number (1-800-96ABUSE). This requirement is binding upon Communfty Partner ~_and its officers, agents, and em loyees: as required by chapters 39_and 415, Florida Statutes. ADDITIONAL ASSURANCES FOR PARTNERS UTILIZING THE CUSTOMER LOOK-UP SYSTEM There is a Level of Communiy Partnership that allows limited access to customer information to certain personnel who are actively partiapating in assisting the customer in establishing eligibility for ACCESS programs. Partners designated at this level shall perform the following: Assist customers in completing the web application as requested. Partnors that assist the customer completing screens on the web application shall have the customer submit the electronic application themselves unless the Community Partner is acting as the authorized ropresentative and has ail required documentation verifying their designation as the authorized representative. Assisi customers to understand what verifications are outstanding and necessary in order for Department to determine eligibility for the Medicaid, Food Stamp or Temporary Cash Assistance programs. • Assist customers with verifying ease status and eligibility information. Assist customers with understanding the availability of public assistance benefits and services administered by Department • Notify Departmentrf Partner has case information in its possession, custody, or control comceming a customer that is inconsistent with Department's information. Follow Department policies regarding obtaining information not available on the Customer Look-Up system Prior to viewing customer case file information, a Partner using the Customer Look-up System will obtain written consent or authorization from the applicant or recipient authodimg Department to sham confidential public assistance case file information related to eligibility determination wKh the Communiy Partner organization. The consent or authorization shall comply with Department policies and must be available to Department or its designated representatives, as necessary, during normal business hours for review and comparison against inquiries made on the ACCESS system for a period of three years from the date such consent or authorization is received from the applicant, recipient, or authorized household representative. must complete and submit all designated security fortes for each individual allowed al customer case file information as required by Department. Community Partner must liaison of termination of any Community Partner employees that have or had access to __ - - -- DEPARTMENT ASSURANCES Training i ! Depanment will offer training to Community Partner in the following areas: (1) the use or disGosure of confidential customer case file information, including information governed by the Health Insurance Portability and Accountability Act of 1996 and its implementing federal regulations; (2) an overview of ; the available public assistance benefds and services offered by Department; (3) the application process for public assistance programs; (4) Department's ACCESS Florida initiative and Community Partner's role in the initiative; and (5)) for a Partner using the Customer Look-up System only, i Uaining in the use of the confidential customer information through the ACCESS system and the i information contained therein: and (6) Annual Security Awareness Training. ~ Supplies and Materials Department will supply and replenish ACCESS signage, paper applications and public assistance programs literature as needed at no cost to Community Partner. Community Partner must notify Department of the need for additional literature in a timely manner based on its local demand levels. Eligibility Determination 1 Department wilt complete the eligibility determination process on completed applications received i from Community Partner site(s), including timely nofdying applicants of the eligibilfty decision, the availabildy of hearing rights, and how fair hearings may be requested. For Partner using the Customer Look-up System I Department will provide limited access to confidential customer case file information. This access {I will be granted solely to assist the Community Partner in their limited role of assisting with the administration of ACCESS Florida services. The department will monitor Community Partner's compliance with the terms and conditions of customer consent or authorization relating to information concerning applicant and recipient households and assistance groups. Monitoring will occur using on-site visits, computerized surveillance, desk reviews and by other means deemed necessary by Department. ---' MUTUA<_AGREEMENT Start Date and End Date ^ This agreement shall begin on , or on the date on which it is signed by the last party required to sign it, whichever is latest. It shall end at midnight, local time in ovation ,Florida, on ^ This agreement will remain in effect unless terminated by ether party with proper notice. Termination 1. This agreement can be terminated by either party without cause upon no less than'30 calendar days notice in writing to the other party, unless an earlier time is mutually agreed upon in writing. ' 2. This agreemerrt may be terminated for Community Partner's non-pertormance upon no less than 24 hours notice in writing by Department. Department may exercise the provisions of Rule 60A- 1.OD6(3), Florida Administrative Code, if this agreement is terminated for nonperformance. Waiver of any breach of this agreement shalt not be deemed a waiver of any other breach and shall not be construed to be a modification of this agreement. Department may exercise alt other rights and remedies at law or in equity to redress a broach of this agreement 3. Community Partner's failure to perform any obligation required by this agreement in a manner satisfactory to DeparUnent will be sufficient cause to terminate this agreement. To be terminated as a partner under this subparagraph, Community Partner must have: (1) previously failed fo satistailorily pertorm in a contrail with Department, been noted by Department of the unsatisfactory pertormance, and failed to cored the unsatisfactory perormance to Department's satisfaction; or (2) had a contract terminated by Department for cause. The contact person, or their designee, shall be responsible for informing the appropriate local Department of Children and Families office of performance concerns of which the Communty Partner becomes aware in the pertormance of its duties and responsibilities, and be responsible for providing in a timely manner the appropriate local Department of Children and Families office with original or copies of documentation required by this agreement, and for being available to Department for consultation and assistance, as requested by Department or as agreed by Cormunty Partner, during Community Partner's normal business hours and days of operation. 1.Community Partner's name, as shown on page 1, mailing address, telephone number and a-mail address is: t~.Qf_MiQml _.._~j(_c_ ^ Imut;t Sfk/f~! 1. DLCmue ~ ~ ~I}~~ ~ ~ ~. -- _ iAml_._,~patl1__. ~6 331 _.._ X05- E73-_~J4G1 _ ..._ 2. The name, address, telephone number and a-mail address of Department of Children and Families ACCESS Program contact person is: __ __ _ _ -. I L L I ~I,tL 107 aye __ .__ _(u~ar»r, 1. 3~ Ib~- -- -~ .~_ z ~ 5~, ~r.u , . vrzo c~c~. "rc ft. u Department's contact person will be available to assist Community Partner in its performance of this agreement on an "as needed" basis during Department's norrnal business hours and days of '~ operation. All contact with Uepartrnent by the Community Partner must be through Department's a local contact porson, _ -- .---- SIGNATURES ~ Signature of Community Agency ~~ ~ ~~~ . ~ 9 Executive or Designee _ ;'- j - / 1 Date LJ Printed Name of the Executive or Jae M. Gonzalez, C1ty_ PSana&er~/3~ l Designee r ~- - Attest: ~~~~~~ ~~ `"^' Rober[ Parcher, City Clerk y Da~6el Datle Signature of DCF Regional -- -- - Date Director, Circuit Administrator or Designee Printed Name of the Regional -- -- - -- - Director, Circuit Administrator or Date Designee gpPROVED AS TO FORM 8~ LANGUAGE FOR CUTION ~h~ ~ ~f D f it mey ~ e ~~ rne,rx.a~in~rTV Pe A'PNTi.R I'~1~l IR AfA Community Partner ~:;i~ of Mtar~~ $eACh OFfite of Cormunr+y S~'`"~o~te: _ 0312? ~ ~°9 Addrew: (1~'~ ~ (~~e~,n,~`1"04) ~V1tE( ~ ~- _ _ _ Phoue: ~-1c7p3,_ Ciq•; MIG1Wt 1 4.l;ut,V 1 Stale: ~ Zip Cade : 3 313 I C. P. Contact Person: ~ ~ 0.Y1(A Rl.(1 L C. P. Contact Person: ~ YGt°~ a ~ZU.b10 E-Mxil AAdress: CV1Cil't~(.f1A1 Z ~ MIQYVIt pCAGlrt~l - 9 UV E-AfailAddre~s; f"~nYCPIG1rLtl'il()~~tQmt~aGl~FI-C~GU J}CF Contact Pcrsoo . Phone - Equipment a~~sila6lc un site: Yes Nu Yes No Yes No ~1 ^ Computer ^ ^ Printer ~ ^ Sc:mner Expected volume of applications: N 1 _ N of computers needed fur cspected volume: ~_ Commuuit}' Partner staff idcntiGed to be trained: :Dread} Alrcadv Trained Trained NAME Yes Nu NAA1E Yes Nu fuG K~ ~i ~-b' a __ ^ ® ~' r t s~fii na C~re~-a _ ^ Carmelti ~ YI nova ro . _ ^ ® :)ehne. flerre- Luis __ ^ EIv;S NuGtC'L ^ ~ ^ ^ ~aimage 'rh~rLt;ll ^ ~ ^ ^ COMMENTS: THIS SECTION COMPI,ETEU BY DEPARTMENT OF CHILDREN AND FAMILIES: Potential Commmnity Partner: Yes ^ No ^ If ties, which ACCESS Level has the Community Partner committed to AssisG:d Site ^ Self Service Site ^ Information Sitc ^ Route Web Application to County Number,~Administmtive Unit Number. __-. _ Partner will sen~e^ General Public~__..~ Traditional Base _, _ Has the Community Partner n:yuested funding? __ Yes ___ __.__ No ' lIf ve'9, ho~v much has been requested'? _ . _ ACCESS Program OflicelSfISPS Daisy 13efmUdeZl _