Common use of TERMINATION OF AGREEMENT AND APPEALS Clause in Contracts

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 and Section IV.9 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 Provider assigned physicians, 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. PROVIDER DEPT OF HEALTH & SOCIAL SERVICES Signature of Provider Representative & Date Signature of DHSS Representative & Date Printed Name Provider Representative & Title Printed Name DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant 0000 Xxxxx Xxxxxx Anchorage, Alaska 99508-3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx Xxxxx, Grants Administrator Grants & Contracts Support Team P.O. Box 110650 Federal Tax ID Number Juneau, AK 00000-0000 Phone (000) 000-0000 Fax (000) 000-0000

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS DFCS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I and Section IV.9 of this Agreement. Notification of non-eligibility ineligibility 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 DHSSDFCS. A Provider may appeal the a decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals Appeals will be conducted in accordance with Section 7AAC 7 AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS DFCS may terminate this Agreement with 30 days days’ notice. A Provider may also terminate the Agreement with 30 days days’ notice, but and must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Provider assigned physicians, Providers as directed by DHSSDFCS. This Agreement remains in force until the Provider or DHSS DFCS 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, its appendices, and its attachments. PROVIDER DEPT OF HEALTH FAMILY & SOCIAL COMMUNITY SERVICES Signature of Authorized Provider Representative & Date Data Signature of DHSS DFCS Representative & Date Data Printed Name & Title of Provider Representative Printed Name & Title Printed Name DHSS of DFCS Representative & Title Provider Contact DFCS Contacts & Mailing Address DHSS Contacts & PROGRAM UNIT Xxxxxx X Xxxxxx-Xxxx, Program Coordinator 2 Provider Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant 0000 Xxxxx Xxxxxx Anchorage, Alaska 99508-3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx Xxxxx, Grants Administrator Grants & Contracts Support Team P.O. Address Division of Juvenile Justice PO Box 110650 Federal Tax ID Number Juneau, AK 00000-0000 Phone Phone: (000) 000-0000/Fax: (000) 000-0000 Provider Phone Number/Fax Number Xxxxxx.Xxxxxx-Xxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Xxxxx Xxxxxxxx, Grants Administrator Provider Email Address Grants & Contracts Support Team PO Box 110650 Juneau, AK 99811-0650 Provider’s Federal Tax ID Number Phone: (000) 000-0000/Fax: (000) 000-0000 Xxxxx.xxxxxxxx@xxxxxx.xxx Providers must identify the business entity type under which they are legally eligible to provide service and intending to enter into this Provider Agreement. Confirm entity type below. Non-Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) SUBMITTAL CHECKLIST Scan the following documents as a single file. The Provider Agreement section is 4.06, Question 1. The following documents, each completed and signed by an authorized agency signer: Provider Agreement, first and last pages or the entire document; Provider Agreement Appendix C, Federal Assurances and Certifications; Provider Agreement Appendix D, Federal EEOP Certifications; and Request for Waiver of Staff Requirement(s) if requesting The uploaded file must also include

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 and Section IV.9 of this Agreement. Notification of non-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-non- payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.20081.205. All appeals will be conducted in accordance with Section 7AAC 81.20081.205-210 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 Provider assigned physiciansProviders, 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. PROVIDER DEPT DEPT. OF HEALTH & SOCIAL SERVICES Signature of Provider Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant Xxxxx Xxxxx, Behavioral Health Emergency Services Coordinator Division of Behavioral Health 0000 “X” Xxxxxx, Xxxxx Xxxxxx 000 Anchorage, Alaska 99508AK 99503 D: (000) 000-3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx 0000; (000) 000-0000 ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx XxxxxXxxxxx, Grants Administrator Grants & Contracts Support Team P.O. PO Box 110650 Juneau, AK 99811-0650 Federal Tax ID Number Juneau, AK 00000-0000 Phone (000) 000-0000 Fax (000) 000-0000Xxxxxx.Xxxxxx@xxxxxx.xxx

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 and Section IV.9 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 days’ notice. A Provider may also terminate the Agreement with 30 days days’ notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Provider assigned physiciansProviders, 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 DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxxxx, Administrative Assistant III Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant 0000 Xxxxx Xxxxxx Anchorage, Alaska 99508-3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT 4677 000-000-0000 / Fax 000-000-0000 Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Grants Administrator Grants III _ Dept. of Health & Contracts Support Team Social Services Provider Email Address P.O. Box 110650 Juneau, AK 99811-0650 _ Ph. 000-000-0000 / Fax 000- 000-0000 Provider’s Federal Tax ID Number Juneau, AK 00000-0000 Phone (000) 000-0000 Fax (000) 000-0000Number

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 and Section IV.9 of this Agreement. Notification of non-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-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 days’ notice. A Provider may also terminate the Agreement with 30 days days’ notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Provider assigned physicianspractitioners, 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. PROVIDER DEPT OF HEALTH & SOCIAL SERVICES Signature of Provider Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name DHSS Representative & &Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant 0000 Xxxxx Xxxxxx Anchorage, Alaska 99508-3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx XxxxxXxxxxxxxx Xxxxxxx, Grants Administrator Grants & Contracts Support Team P.O. Box 110650 Federal Tax ID Number Juneau, AK 00000-0000 Phone (000) 000-0000 Fax (000) 000-00000000 Xxxxxxxxx.Xxxxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS DFCS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I and Section IV.9 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 DHSSDFCS. 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 DFCS may terminate this Agreement with 30 days days’ notice. A Provider may also terminate the Agreement with 30 days days’ notice, but must provide assistance in making arrangements for safe and orderly transfer of clients Clients and information to other Provider assigned physiciansProviders, as directed by DHSSDFCS. This Agreement remains in force until the Provider or DHSS DFCS 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 DEPT. OF HEALTH FAMILY & SOCIAL COMMUNITY SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS DFCS Representative & Date Xxxxxx Xxxxx, Grants & Contracts Chief Printed Name Provider Representative & Title Printed Name DHSS - DFCS Representative & Title Provider Contact & Mailing Address DHSS DFCS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxx Xxxxxxx, Chief Financial Officer Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant 0000 Xxxxx Xxxxxx Anchorage, Alaska 99508AK, 00000-3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT 0000 Phone 000.000.0000 Fax 000.000.0000 xxxxx.xxxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number Xxxxxx XxxxxADMINISTRATIVE CONTACT Xxxxx Xxxxxxxx, Grants Administrator Grants & Contracts Support Team P.O. Provider Email Address PO Box 110650 Federal Tax ID Number Juneau, AK 0000099811-0000 Phone (0650 Ph. 000) -000-0000 Fax (000) 000-0000000-0000 Provider’s IRIS Vendor Number Questions on the PA: xxxxx.xxxxxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS FCS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I and Section IV.9 of this Agreement. Notification of non-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-non- payment and automatic termination of the Agreement by DHSSFCS. 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 FCS may terminate this Agreement with 30 days days’ notice. A Provider may also terminate the Agreement with 30 days days’ notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Provider assigned physicianspractitioners, as directed by DHSSFCS. This Agreement remains in force until the Provider or DHSS FCS terminates the Agreement or a material term of the Agreement is changed. PROVIDER DEPT OF HEALTH FAMILY & SOCIAL COMMUNITY SERVICES Signature of Provider Representative & Date Signature of DHSS DFCS Representative & Date Printed Name Provider Representative & Title Printed Name DHSS Representative & Title Xxxx Xxxxxxxx, Division Operations Manager Provider Contact & Mailing Address DHSS DFCS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant Attn: API Contracts Office 0000 Xxxxx Xxxxxx Anchorage, Alaska AK 99508-3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx xxx.xxx.xxxxxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx XxxxxXxxxxxxxxx Xxxxxxx, Grants Administrator Grants & Contracts Support Team Family and Community Services P.O. Box 110650 112650 Federal Tax ID Number Juneau, AK 00000-0000 Phone (000) 000-0000 Fax (000) 000-00000000 Xxxxxxxxxx.Xxxxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider Consultant agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements qualifications set out in Section I and Section IV.9 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 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 Provider 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 Provider assigned physiciansservice providers, as directed by DHSS. This Agreement remains in force until the Provider Consultant or DHSS terminates the Agreement or a material term of the Agreement is changed. PROVIDER DEPT CONSULTANT DEPT. OF HEALTH & SOCIAL SERVICES Signature of Provider Consultant Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx -DHSS Representative Division Chief, Grants & Contracts Printed Name Provider Consultant Representative & Title Printed Name DHSS Representative & Title Provider Support Team Consultant Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant Xxxx Xxxxxxxx, Mental Health Clinician III Division of Behavioral Health 0000 X Xx., Xxxxx Xxxxxx 000 Anchorage, Alaska 99508AK 99503 Phone(907) 000-3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider 0000 / Fax (000) 000-0000 Consultant Phone Number/ Fax Number Consultant’s Federal Tax ID Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxxx, Grants Administrator Grants & Contracts Support Team P.O. PO Box 110650 Federal Tax ID Number Juneau, AK 0000099811-0000 Phone 0650 (000) 000-0000 / Fax (000) 000-00000000 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 and Section IV.9 of this Agreement. Notification of non-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-non- payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.20081.205. All appeals will be conducted in accordance with Section 7AAC 81.20081.205-210 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 Provider assigned physiciansProviders, 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. PROVIDER DEPT DEPT. OF HEALTH & SOCIAL SERVICES Signature of Provider Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant Xxxxxxx X. Xxxxx, M.S., Behavioral Health Emergency Services Program Specialist Division of Behavioral Health 0000 “X” Xxxxxx, Xxxxx Xxxxxx 000 Anchorage, Alaska 99508AK 99503 P: (000) 000-3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx 0000; (000) 000-0000 ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx Xxxxx Xxxxx, Grants Administrator Grants & Contracts Support Team P.O. PO Box 110650 Federal Tax ID Number Juneau, AK 0000099811-0000 Phone (000) 000-0000 Fax (000) 000-00000650