Common use of Xxxx Xxx Clause in Contracts

Xxxx Xxx. xx.xxx/eligibility ➢ From the Login Center Transaction Services screen, enter Userid: your provider number preceded by 5 zeros ➢ Enter state assigned password - call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ Click on Submit or press enter ➢ From the Transaction Services screen, double click on Determine Share of Cost ➢ From Perform SOC screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, and clearing service for the current month, enter today’s date. If you are clearing a retroactive service, you must have the BIC issue date. (mm/dd/yyyy) ▪ Date of Service – enter service date for the “SOC Clearance.” (mm/dd/yyyy) ▪ Procedure Code – enter the procedure code for which the SOC is being cleared. The procedure code is required. (90862, 90841, 90882, etc.) ▪ Billed Amount – enter the amount in dollars and cents of the total xxxx for the procedure code. (ex. 100 dollars would be entered as 100.00). If you do not specify a decimal point, a decimal followed by two zeros will be added to the end of the amount entered. ▪ Share of Cost Case Number – optional unless applying towards family member’s SOC case ▪ Amount of Share of Cost – optional unless a SOC case number was entered ▪ Click on Submit or press enter Note: Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data. Select SOC Case – this item affects how the Patient Recall button (described above) functions. Simply select the circle above the SOC case number that you want the Patient Recall button to use when it fills out the form. Note that the SOC case numbers are only available if the previous transaction was an Eligibility transaction. The “Last Used” choice contains the SOC Case number that was used if the previous transaction was a SOC transaction. This is also a default choice if none are selected. ATTACHMENT I Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, as Amended The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b)

Xxxx Xxx. xx.xxx/eligibility ➢ From the Login Center Transaction Services screen, enter Userid: your provider number preceded by 5 zeros ➢ Enter state assigned password - call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ Click on Submit or press enter ➢ From the Transaction Services screen, double click on Determine Share of Cost ➢ From Perform SOC screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, and clearing service for the current month, enter today’s date. If you are clearing a retroactive service, you must have the BIC issue date. (mm/dd/yyyy) ▪ Date of Service – enter service date for the “SOC Clearance.” (mm/dd/yyyy) ▪ Procedure Code – enter the procedure code for which the SOC is being cleared. The procedure code is required. (90862, 90841, 90882, etc.) ▪ Billed Amount – enter the amount in dollars and cents of the total xxxx for the procedure code. (ex. 100 dollars would be entered as 100.00). If you do not specify a decimal point, a decimal followed by two zeros will be added to the end of the amount entered. ▪ Share of Cost Case Number – optional unless applying towards family member’s SOC case ▪ Amount of Share of Cost – optional unless a SOC case number was entered ▪ Click on Submit or press enter Note: Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data. Select SOC Case – this item affects how the Patient Recall button (described above) functions. Simply select the circle above the SOC case number that you want the Patient Recall button to use when it fills out the form. Note that the SOC case numbers are only available if the previous transaction was an Eligibility transaction. The “Last Used” choice contains the SOC Case number that was used if the previous transaction was a SOC transaction. This is also a default choice if none are selected. ATTACHMENT I Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, as Amended The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b)E

Xxxx Xxx. xx.xxx/eligibility ➢ ⮚ From the Login Center Transaction Services screen, enter Userid: your provider number preceded by 5 zeros ➢ ⮚ Enter state assigned password - call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ ⮚ Click on Submit or press enter ➢ ⮚ From the Transaction Services screen, double click on Determine Share of Cost ➢ ⮚ From Perform SOC screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, and clearing service for the current month, enter today’s date. If you are clearing a retroactive service, you must have the BIC issue date. (mm/dd/yyyy) ▪ Date of Service – enter service date for the “SOC Clearance.” (mm/dd/yyyy) ▪ Procedure Code – enter the procedure code for which the SOC is being cleared. The procedure code is required. (90862, 90841, 90882, etc.) ▪ Billed Amount – enter the amount in dollars and cents of the total xxxx for the procedure code. (ex. 100 dollars would be entered as 100.00). If you do not specify a decimal point, a decimal followed by two zeros will be added to the end of the amount entered. ▪ Share of Cost Case Number – optional unless applying towards family member’s SOC case ▪ Amount of Share of Cost – optional unless a SOC case number was entered ▪ Click on Submit or press enter Note: Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data. Select SOC Case – this item affects how the Patient Recall button (described above) functions. Simply select the circle above the SOC case number that you want the Patient Recall button to use when it fills out the form. Note that the SOC case numbers are only available if the previous transaction was an Eligibility transaction. The “Last Used” choice contains the SOC Case number that was used if the previous transaction was a SOC transaction. This is also a default choice if none are selected. ATTACHMENT I Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, as Amended The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b)

Xxxx Xxx. xx.xxx/eligibility ➢ ⮚ From the Login Center Transaction Services screen, enter Userid: your provider number preceded by 5 zeros ➢ ⮚ Enter state assigned password - call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ ⮚ Click on Submit or press enter ➢ ⮚ From the Transaction Services screen, double click on Determine Share of Cost ➢ ⮚ From Perform SOC screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, and clearing service for the current month, enter today’s date. If you are clearing a retroactive service, you must have the BIC issue date. (mm/dd/yyyy) ▪ Date of Service – enter service date for the “SOC Clearance.” (mm/dd/yyyy) ▪ Procedure Code – enter the procedure code for which the SOC is being cleared. The procedure code is required. (90862, 90841, 90882, etc.) ▪ Billed Amount – enter the amount in dollars and cents of the total xxxx for the procedure code. (ex. 100 dollars would be entered as 100.00). If you do not specify a decimal point, a decimal followed by two zeros will be added to the end of the amount entered. ▪ Share of Cost Case Number – optional unless applying towards family member’s SOC case ▪ Amount of Share of Cost – optional unless a SOC case number was entered ▪ Click on Submit or press enter Note: Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data. Select SOC Case – this item affects how the Patient Recall button (described above) functions. Simply select the circle above the SOC case number that you want the Patient Recall button to use when it fills out the form. Note that the SOC case numbers are only available if the previous transaction was an Eligibility transaction. The “Last Used” choice contains the SOC Case number that was used if the previous transaction was a SOC transaction. This is also a default choice if none are selected. ATTACHMENT I Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, as Amended The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b).

Xxxx Xxx. xx.xxx/eligibility ➢ From the Login Center Transaction Services screen, enter Userid: your provider number preceded by 5 zeros ➢ Enter state assigned password - call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ Click on Submit or press enter ➢ From the Transaction Services screen, double click on Determine Share of Cost ➢ From Perform SOC screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, and clearing service for the current month, enter today’s date. If you are clearing a retroactive service, you must have the BIC issue date. (mm/dd/yyyy) ▪ Date of Service – enter service date for the “SOC Clearance.” (mm/dd/yyyy) ▪ Procedure Code – enter the procedure code for which the SOC is being cleared. The procedure code is required. (90862, 90841, 90882, etc.) ▪ Billed Amount – enter the amount in dollars and cents of the total xxxx for the procedure code. (ex. 100 dollars would be entered as 100.00). If you do not specify a decimal point, a decimal followed by two zeros will be added to the end of the amount entered. ▪ Share of Cost Case Number – optional unless applying towards family member’s SOC case ▪ Amount of Share of Cost – optional unless a SOC case number was entered ▪ Click on Submit or press enter Note: Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data. Select SOC Case – this item affects how the Patient Recall button (described above) functions. Simply select the circle above the SOC case number that you want the Patient Recall button to use when it fills out the form. Note that the SOC case numbers are only available if the previous transaction was an Eligibility transaction. The “Last Used” choice contains the SOC Case number that was used if the previous transaction was a SOC transaction. This is also a default choice if none are selected. ATTACHMENT I Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, as Amended The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b)Attachment D - Payor Financial Form SAMSHA Certifications – Attachment 2 CERTIFICATIONS CERIFICATION REGARDING LOBBYING

Xxxx Xxx. xx.xxx/eligibility ➢ From the Login Center Transaction Services screen, enter Userid: your provider number preceded by 5 zeros ➢ Enter state assigned password - call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ Click on Submit or press enter ➢ From the Transaction Services screen, double click on Determine Share of Cost ➢ From Perform SOC screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, and clearing service for the current month, enter today’s date. If you are clearing a retroactive service, you must have the BIC issue date. (mm/dd/yyyy) ▪ Date of Service – enter service date for the “SOC Clearance.” (mm/dd/yyyy) ▪ Procedure Code – enter the procedure code for which the SOC is being cleared. The procedure code is required. (90862, 90841, 90882, etc.) ▪ Billed Amount – enter the amount in dollars and cents of the total xxxx for the procedure code. (ex. 100 dollars would be entered as 100.00). If you do not specify a decimal point, a decimal followed by two zeros will be added to the end of the amount entered. ▪ Share of Cost Case Number – optional unless applying towards family member’s SOC case ▪ Amount of Share of Cost – optional unless a SOC case number was entered ▪ Click on Submit or press enter Note: Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data. Select SOC Case – this item affects how the Patient Recall button (described above) functions. Simply select the circle above the SOC case number that you want the Patient Recall button to use when it fills out the form. Note that the SOC case numbers are only available if the previous transaction was an Eligibility transaction. The “Last Used” choice contains the SOC Case number that was used if the previous transaction was a SOC transaction. This is also a default choice if none are selected. ATTACHMENT I Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973E FINGERPRINTING CERTIFICATION Contractor hereby certifies that Contractor’s employees, as Amended The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973volunteers, as amendedconsultants, all requirements imposed by the applicable DHHS regulationagents, and all guidelines any other persons who provide services under this Agreement and interpretations issued pursuant theretowho has/will have supervisory or disciplinary power over a child (Penal Code Section 11105.3) (the “Applicant”) shall be fingerprinted in order to determine whether each such Applicant has a criminal history which would compromise the safety of children with whom each such Applicant has/will have contact. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s)Contractor’s employees, its successorsvolunteers, transfereesconsultants, agents, and assignees, and the person or any other persons whose signatures appear below are authorized to sign who provide services under this assurance on behalf of the Contractor(s). The Contractor(s): Agreement: (Check check a or b) a. do NOT exercise supervisory or disciplinary power over children (Penal 11105.3).

Xxxx Xxx. xx.xxx/eligibility ➢ From the Login Center Transaction Services screen, enter Userid: your provider number preceded by 5 zeros ➢ Enter state assigned password - call Medi-Cal Provider Relations Phone Support @ 0-000-000-0000 ➢ Click on Submit or press enter ➢ From the Transaction Services screen, double click on Determine Share of Cost ➢ From Perform SOC screen fill in the following fields: ▪ Recipient ID – enter the client’s Social Security # (without dashes) ▪ Date of Birth – enter the client’s DOB (mm/dd/yyyy) ▪ Date of Card Issue – if unknown, and clearing service for the current month, enter today’s date. If you are clearing a retroactive service, you must have the BIC issue date. (mm/dd/yyyy) ▪ Date of Service – enter service date for the “SOC Clearance.” (mm/dd/yyyy) ▪ Procedure Code – enter the procedure code for which the SOC is being cleared. The procedure code is required. (90862, 90841, 90882, etc.) ▪ Billed Amount – enter the amount in dollars and cents of the total xxxx for the procedure code. (ex. 100 dollars would be entered as 100.00). If you do not specify a decimal point, a decimal followed by two zeros will be added to the end of the amount entered. ▪ Share of Cost Case Number – optional unless applying towards family member’s SOC case ▪ Amount of Share of Cost – optional unless a SOC case number was entered ▪ Click on Submit or press enter Note: Click on Back - to return to Transaction Services screen Clear – press this button to clear the fields in the form Patient Recall – once any transaction has been performed on a client, pressing this button will fill in the common fields with all of the information from the last transaction. This is useful for using the same client on different transaction (such as an eligibility verification, then a Share of Cost) or for correcting data when a transaction has gone through with incorrect data. Select SOC Case – this item affects how the Patient Recall button (described above) functions. Simply select the circle above the SOC case number that you want the Patient Recall button to use when it fills out the form. Note that the SOC case numbers are only available if the previous transaction was an Eligibility transaction. The “Last Used” choice contains the SOC Case number that was used if the previous transaction was a SOC transaction. This is also a default choice if none are selected. Attachment D - Payor Financial Form ATTACHMENT I Assurance of Compliance with Section 504 of the Rehabilitation Act of 1973, as Amended The undersigned (hereinafter called the "Contractor(s)") hereby agrees that it will comply with Section 504 of the Rehabilitation Act of 1973, as amended, all requirements imposed by the applicable DHHS regulation, and all guidelines and interpretations issued pursuant thereto. The Contractor(s) gives/give this assurance in consideration of for the purpose of obtaining contracts after the date of this assurance. The Contractor(s) recognizes/recognize and agrees/agree that contracts will be extended in reliance on the representations and agreements made in this assurance. This assurance is binding on the Contractor(s), its successors, transferees, and assignees, and the person or persons whose signatures appear below are authorized to sign this assurance on behalf of the Contractor(s). The Contractor(s): (Check a or b)