PROVIDER COVERED SERVICES. I confirm that the PROVIDER/ENTITY named herein will be providing the service(s) listed below for enrollees of provider network for Medicaid, Medicare, and other programs (“PLAN”) (as applicable) on behalf of the Plan. (Check applicable services below) ☐ Adult Companion Services ☐ Adult Day Health Services ☐ Assisted Living Facilities ☐ Assistive Care Services ☐ Attendant Services ☐ Behavior Management ☐ Caregiver/Family/Skill Training ☐ Case Management ☐ Chore Services ☐ Consumable Medical Supplies ☐ Dental Services ☐ Home/Environmental Accessibility Adaptation ☐ Escort Services ☐ Financial Assessment/Risk Management ☐ Hearing Services ☐ Home Delivered Meals ☐ Homemaker Services ☐ Hospice ☐ Intermittent & Skilled Nursing ☐ Medical Equipment ☐ Medication Administration ☐ Medication Management ☐ Nursing Facility Care ☐ Nutrition/Risk Reduction ☐ Occupational Therapy ☐ Personal Care Services ☐ PERS (Emergency Response System) ☐ Physical Therapy ☐ Respite Care Services ☐ Respiratory Therapy ☐ Speech Therapy ☐ Vision Services ☐ Transportation ☐ Other: Signature X Date: Abuse, Neglect, and Exploitation Training Attestation All providers, who are mandated reporters of abuse, neglect, and exploitation, must attest that their staff has received the appropriate training. Please complete this Attestation by marking next to the applicable statement. We are a mandated reporter of Abuse, Neglect, and Exploitation. Our staff has received the appropriate training and update training as applicable. We are current with this requirement. We are NOT a mandated reporter of Abuse, Neglect, and Exploitation and will update this attestation should we become a mandated reporter. Additionally, all providers and their employees with direct contact with enrollees must have completed Abuse, Neglect, and Exploitation Training. Please complete this Attestation as evidence of your compliance by marking next to the applicable statement. Our license requires that we provide Abuse, Neglect, and Exploitation training to our direct care staff upon orientation and annually. We are current with this requirement. Our licensure requires that we provide Abuse, Neglect, and Exploitation training to our direct care staff upon orientation only. We are current with the requirement. Our license does not require Abuse, Neglect, and Exploitation Training; however our policy and procedures require our staff to have this in-service training upon orientation. We are current with this requirement. Our licen...
PROVIDER COVERED SERVICES. During the Term, PROVIDER shall provide to the PROVIDER Medicare Members the Services set forth, together with their respective CPT codes and/or definitions (as applicable) and their respective Core Non-Pharmacy Payments (as defined in Section 4.1(a) below), on Exhibit 1, as the same may be amended from time to time in accordance with Section 4.5(c) (the “PROVIDER Core Services”); provided, however, that, notwithstanding anything in this Agreement to the contrary, if any PROVIDER Medicare Member selects or is assigned as their primary care physician a physician who primarily practices in an Affiliated Provider, or in a PROVIDER Medical Center that does not provide transportation to the Approved PLAN Operating Area where such PROVIDER Medicare Member resides, then PROVIDER shall have the right, in its sole discretion, to withhold the transportation benefit that is part of the PROVIDER Core Services with respect to such PROVIDER Medicare Member unless and until either (i) such PROVIDER Medicare Member selects or is assigned as their primary care physician a physician who practices at the PROVIDER Medical Center(s), if any, that provides transportation to the Approved PLAN Operating Area where such PROVIDER Medicare Member resides, as designated by PROVIDER and communicated to PLAN in writing from time to time, or (ii) the physician selected by or assigned to such PROVIDER Medicare Member as their primary care physician relocates his or her practice to a PROVIDER Medical Center, if any, that provides transportation to the Approved PLAN Operating Area where such PROVIDER Medicare Member resides. Except as specifically set forth in Section 4.5(c) or as expressly agreed to in a writing executed by each of PLAN and PROVIDER, the PROVIDER Core Services shall in no event be expanded, curtailed or otherwise modified at any time during the Term. In addition to the PROVIDER Core Services, PROVIDER shall provide to the PROVIDER Medicare Members the Services set forth, together with their respective CPT codes and/or definitions (as applicable) and their respective Additional Services Capitation Payments (as defined in Section 4.2 below), on Exhibit 2, as the same may be amended from time to time in accordance with Section 3.2 below (the “PROVIDER Additional Services”). The PROVIDER Core Services and PROVIDER Additional Services are referred to together as the “PROVIDER Covered Services.”
