Common use of CDSA Clause in Contracts

CDSA. Date Services to Begin (if submitting new Provider Agreement):  / /  Name of Service Provider Agency:   Mailing Address:   Telephone #: ( ) -  Cellular Phone #: ( ) -  Fax #: ( ) -  Primary contact person:   Email:   Alternate contact person:   Email:   Service Provider Plan:                                           *Indicate any of the following: PT, OT, SP, Special Instruction (CBRS), AUDIO **Indicate maximum number of ITP children/families you are able to serve in this county per service at any given time     Printed Name of Authorized Representative Name of Service Provider Organization   Signature of Authorized Representative Date of Signature   Signature of CDSA Finance Officer Date of Signature   Signature of CDSA Director Date of Signature Send Plan / Agreement Amendment to: Insurances current? Prof / Gen / WC / Auto Y   / N   Date Initial Agreement Effective   Effective Period of Renewal #1   Effective Period of Renewal #2   Agreement Termination Date   Background/OIG check   Date:   Service Provider Agency:   Please fill out only the sections for which you are requesting changes.

CDSA. Date Services to Begin (if submitting new Provider Agreement):  / /  Name of Service Provider Agency:   Mailing Address:   Telephone #: ( ) -  Cellular Phone #: ( ) -  Fax #: ( ) -  Primary contact person:   Email:   Alternate contact person:   Email:   Service Provider Plan:                                           *Indicate any of the following: PT, OT, SP, Special Instruction (CBRS), AUDIO **Indicate maximum number of ITP children/families you are able to serve in this county per service at any given time     Printed Name of Authorized Representative Name of Service Provider Organization   Signature of Authorized Representative Date of Signature   Signature of CDSA Finance Officer Date of Signature   Signature of CDSA Director Date of Signature Send Plan / Agreement Amendment to: Insurances current? Prof / Gen / WC / Auto Y   / N   Date Initial Agreement Effective   Effective Period of Renewal #1   Effective Period of Renewal #2   Agreement Termination Date   Background/OIG check     Date:   Service Provider Agency:   Please fill out only the sections for which you are requesting changes.