DEPARTMENT OF HEALTH SERVICESDepartment of Health Services • May 4th, 2018 • California
, 2014 by and between the County of Los Angeles, hereinafter referred to as County and , hereinafter referred to as Contractor. is located at .
AGREEMENT BETWEEN State of Wisconsin Department of Health ServicesDepartment of Health Services • April 13th, 2020
This agreement is entered into between the Wisconsin Department of Health Services (DHS), administering the WIC Farmers’ Market Nutrition Program and the Senior Farmers' Market Nutrition Program, and the above-named individual, hereinafter referred to as "vendor." Hereinafter, “State Agency” refers to the Department of Health Services. This agreement is for the period beginning April 1, 2020 and will expire on December 31, 2022.
ANNUAL ROSIE USER SECURITY AND CONFIDENTIALITY AGREEMENT ROSIE Information Security Awareness Training is required before signing this agreement. This agreement (and training) must be reviewed annually and documented on the back of this form. User...Department of Health Services • December 11th, 2019
User Role (check all that apply) Local ROSIE Administrator* Local WIC Staff WIC Director PH Agency Supervisor Other PH Agency Staff State Administrator* State WIC Staff* Other (Specify)
DEPARTMENT OF HEALTH SERVICES Division of Care and Treatment Services F-00335 (03/2017) STATE OF WISCONSINDepartment of Health Services • July 31st, 2019
voluntary agreement for CRISIS STABILIZATION services Use of this form is voluntary, but it does meet the requirements of DHS Chapters 48 and § 51.15.
HEALTHCARE ANCILLARY SERVICES MASTER AGREEMENT (HASMA)Department of Health Services • April 30th, 2019
DEPARTMENT OF HEALTH SERVICESDepartment of Health Services • April 28th, 2014 • California
, 2014 by and between the County of Los Angeles, hereinafter referred to as County and , hereinafter referred to as Contractor. is located at .
SENIOR FARMERS’ MARKET NUTRITION PROGRAM (SFMNP) ELIGIBILITY AGREEMENTDepartment of Health Services • May 3rd, 2021
Completion of this form is voluntary. If it is not completed, the applicant will not be eligible to receive the benefits of the Senior Farmers’ Market Nutrition Program.
CHILDREN’S LONG-TERM SUPPORT (CLTS) WAIVER PROGRAM PROVIDER AGREEMENT AND ACKNOWLEDGEMENT OF TERMS OF PARTICIPATIONDepartment of Health Services • May 5th, 2020
Completion of this form is required under Federal Law by the Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, under the Code of Federal Regulations 42 CFR 431.107.
WIC PROGRAM REPAYMENT AGREEMENTDepartment of Health Services • October 2nd, 2019
WIC Kev Pab Cuam rau cov nyiaj tau txais tsis raws cai. Kuv yuav them cov nyiaj raws li tau teem sij hawm hauv qab no. Yog tsis them cov nyiaj raws li tau teem tseg yuav ua rau tag nrho cov neeg hauv kuv tsev neeg tsis muaj feem tau txais kev pab los ntawm WIC Kev Pab Cuam kom txog rau thaum them tas qhov nyiaj puv ntoob rov qab.
VACCINE FOR ADULTS (VFA) PROVIDER AGREEMENTDepartment of Health Services • October 14th, 2020
Please return completed form to: Division of Public Health, Wisconsin Immunization Program, Attn: VFA Program, PO Box 2659 Madison WI 53701-2659.
HEALTHCARE ANCILLARY SERVICES MASTER AGREEMENTDepartment of Health Services • January 31st, 2023
Appendix A Organization Questionnaire/Affidavit and CBE Information Appendix B Minimum Qualification Requirements Verification Appendix C Prospective Contractor References
MEDICARE COUNSELING CLIENT SERVICES AGREEMENT INSTRUCTIONSDepartment of Health Services • April 5th, 2022
The Disability Benefit Specialist Program Medicare Counseling Client Services Agreement (CSA) documents the nature of Medicare counseling and assistance the disability benefit specialist (DBS) has agreed to perform on the client’s behalf. The form explains limitations regarding the DBS’s enrollment counseling and assistance and the confidentiality standards by which the DBS must abide. The Medicare Counseling CSA may be used when the DBS is only providing benefits counseling or enrollment assistance with Medicare Advantage plans (Medicare Part C) and/or Medicare prescription drug plans (Medicare Part D). Use the Disability Benefit Specialist Program Client Services Agreement (F-02562) when providing additional benefits counseling services.
CHILDREN’S LONG-TERM SUPPORT (CLTS) WAIVER PROGRAM PROVIDER AGREEMENT AND ACKNOWLEDGEMENT OF TERMS OF PARTICIPATIONDepartment of Health Services • August 12th, 2020
Completion of this form is required under Federal Law by the Centers for Medicare & Medicaid Services, U.S. Department of Health and Human Services, under the Code of Federal Regulations 42 CFR 431.107.
CONFIDENTIALITY AND NON-DISCLOSURE AGREEMENT - CONTRACTORDepartment of Health Services • April 23rd, 2020
DISABILITY BENEFIT SPECIALIST PROGRAM CLIENT SERVICES AGREEMENT INSTRUCTIONSDepartment of Health Services • January 27th, 2022
The Disability Benefit Specialist Program Client Services Agreement (CSA) documents the nature of services the DBS has agreed to perform on the client’s behalf. The form explains the confidentiality standards by which the DBS must abide and the responsibilities of both the client and DBS.
DEPARTMENT OF HEALTH SERVICESDepartment of Health Services • November 29th, 2016
Personally identifiable information on this form is collected to verify that the application is complete, and will be used only for this purpose.
IRIS PARTICIPANT EMPLOYER / PARTICIPANT- HIRED WORKER AGREEMENTDepartment of Health Services • April 11th, 2014
INSTRUCTIONS: Completion of this form is not required through Wisconsin State Statute; however, completion of this form is an IRIS Program requirement. Both the participant-hired worker and the participant employer must sign and date the bottom in order to be considered complete. Participant-hired worker may not begin working for participant employer until they have received a mailed start date letter. Personally identifiable information on this form is collected to verify that the application is complete, and will be used only for this purpose. Completed forms should be submitted to the participant’s Fiscal Employer Agent.
ADULT PROTECTIVE SERVICES (APS) INVESTIGATION TRANSFER-Model Interagency Agreement between Wisconsin County and Wisconsin CountyDepartment of Health Services • August 20th, 2014
Wisconsin State Statutes §46.90(5)(a)2 and §55.043(1r)(a)2 defines the process for transferring an elder adults/adults-at-risk (EA/AAR) investigation to another county (Transfer County) when the county that received the report (County of Origin) determines that it is unable to perform an unbiased investigation.
