Common use of Provider Agreement Clause in Contracts

Provider Agreement. I declare that I have read and understood the requirements as stated in this document and I agree to comply with these requirements. I further declare that all of the information I have provided on this form is true and correct to the best of knowledge. I agree to notify the county within 10 calendar days if any of the information I have provided in this Provider Workweek and Travel time Agreement changes, and depending on what information has changed, I may be required to complete a new SOC 2255. PROVIDER SIGNATURE: DATE: PROVIDER’S PRINTED NAME: FOR COUNTY USE ONLY WORKER NAME: DATE: ESTIMATED TRAVEL TIME REVIEWED: YES n NO n SOURCE USED TO VERIFY TRAVEL TIME:

Provider Agreement. I declare that I have read and understood the requirements as stated in this document and I agree to comply with these requirements. I further declare that all of the information I have provided on this form is true and correct to the best of knowledge. I agree to notify the county within 10 calendar days if any of the information I have provided in this Provider Workweek and Travel time Agreement changes, and depending on what information has changed, I may be required to complete a new SOC 2255. PROVIDER SIGNATURE: DATE: PROVIDER’S PRINTED NAME: FOR COUNTY USE ONLY WORKER NAME: DATE: ESTIMATED TRAVEL TIME REVIEWED: YES n ◼ NO n ◼ SOURCE USED TO VERIFY TRAVEL TIME:

Provider Agreement. I declare that I have read and understood the requirements as stated in this document and I agree to comply with these requirements. I further declare that all of the information I have provided on this form is true and correct to the best of my knowledge. I agree to notify the county within 10 calendar days if any of the information I have provided in this Provider Workweek and Travel time Agreement changes, and depending on what information has changed, I may be required to complete a new SOC 2255. PROVIDER SIGNATURE: DATE: PROVIDER’S PRINTED NAME: FOR COUNTY USE ONLY WORKER NAME: DATE: ESTIMATED TRAVEL TIME REVIEWED: YES n NO n SOURCE USED TO VERIFY TRAVEL TIME: