TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only for payment in accordance with the payment provision of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect as soon as the agreement is signed by both parties to the agreement. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Administrator Grants & Contracts Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx
TERMINATION OF AGREEMENT AND APPEALS. The Consultant agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider qualifications set out in Section I of this Agreement. Notification of non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Consultant may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days notice. A Consultant may also terminate the Agreement with 30 days notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other service providers, as directed by DHSS. This Agreement remains in force until the Consultant or DHSS terminates the Agreement or a material term of the Agreement is changed. CONSULTANT DEPT. OF HEALTH & SOCIAL SERVICES Signature of Consultant Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx -DHSS Representative Division Chief, Grants & Contracts Printed Name Consultant Representative & Title Support Team Consultant Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxx Xxxxxxxx, Mental Health Clinician III Division of Behavioral Health 0000 X Xx., Xxxxx 000 Anchorage, AK 99503 Phone(907) 000-0000 / Fax (000) 000-0000 Consultant Phone Number/ Fax Number Consultant’s Federal Tax ID Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxxx, Grants Administrator Grants & Contracts Support Team PO Box 110650 Juneau, AK 99811-0650 (000) 000-0000 / Fax (000) 000-0000 Check Entity Type: Private For-profit Business, licensed to do business in the State of Alaska Non Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement, a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA)
TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200 (Request for Appeal). All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days notice. A Provider may also terminate the Agreement with 30 days notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providers, as directed by DHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. RESIDENTIAL CARE FOR CHILDREN & YOUTH (RCCY) ISA PROVIDER AGREEMENT SIGNATURE PAGE PROVIDER / AGENCY INFORMATION Provider Name: Xxxxx # Provider Address: Street / PO City State Zip Provider Federal Tax ID #: Provider Phone #: Provider Fax # I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER: Signature of Provider Authorized Representative Printed Name of Authorized Provider Representative Title of Authorized Provider Representative Date
TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non- payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.205. All appeals will be conducted in accordance with Section 7 AAC 81.205-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other providers, as directed by DHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this Agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this Agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Chief Grants & Contracts Printed Name of Authorized Provider & Title Printed Name of DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxx Xxxxxxx-Xxxxx, Program Manager Division of Behavioral Health P.O. Box 110680 Juneau, AK 00000-0000 Phone: (000) 000-0000 Fax: (000) 000-0000 Email: xxxx.xxxxxxx-xxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxxxx Xxxxxx, Grants Administrator Grants & Contracts Support Team P.O. Box 110650 Juneau, AK 99811-0650 Provider Email Address Phone: (000) 000-0000 Fax: (000) 000-0000 Email: xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Federal Tax ID Number
TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days notice. A Provider may also terminate the Agreement with 30 days notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providers, as directed by DHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed.
TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section II of this Agreement. Notification of non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200 Request for Appeal. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days written notice. A Provider may also terminate the Agreement with 30 days written notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providers, as directed by DHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement By my signature below, I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. Providers must identify the business entity type under which they are legally eligible to provide services and are intending to enter into this Provider Agreement.
TERMINATION OF AGREEMENT AND APPEALS
