Common use of Reference Documents Clause in Contracts

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1A: Title 45, Code of Federal Regulations 96, Subparts C and L, Substance Abuse Prevention and Treatment Block Grant Requirements xxxxx://xxx.xxx.xxx/fdsys/granule/CFR-2005-title45-vol1/CFR-2005- title45-vol1-part96 Document 1B: Title 42, Code of Federal Regulations, Charitable Choice Regulations xxxxx://xxx.xxx.xxxxxxx.xxx/cfr/text/42/part-54 Document 1C: Driving-Under-the-Influence Program Requirements Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J1G: Attachment Y of the DMCPerinatal Services Network Guidelines 2016 Document 1H(a): Service Code Descriptions Document 1J(a): Non-ODS Special Terms and Conditions Drug Medi-Cal Audit Appeals Process Document 1J(b): DMC Audit Appeals Process Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1T: CalOMS Prevention Data Quality Standards Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2C: Title 22, California Code of Regulations xxxx://xxx.xxx.xx.xxx Document 2E: Drug Medi-Cal Certification Standards for Substance Abuse Clinics (Updated July 1, 2004) xxxx://xxx.xxxx.xx.xxx/services/adp/Documents/DMCA_Drug_Medi- Cal_Certification_Standards.pdf Document 2F: Standards for Drug Treatment Programs (October 21, 1981) xxxx://xxx.xxxx.xx.xxx/services/adp/Documents/DMCA_Standards_for_ Drug_Treatment_Programs.pdf Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/Info%20Notice%2020 15/DMC_Billing_Manual%20FINAL.pdf Document 2K: Multiple Billing Override Certification (MC 6700) Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMCDrug Medi-ODS Cal Cost Report Excel Workbook Forms – Intensive Outpatient Treatment – Non-Perinatal (form and instructions) Document 2P(b): Drug Medi-Cal Cost Report Forms – Intensive Outpatient Treatment – Perinatal (form and instructions) Document 2P(c): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Non-Perinatal (form and instructions) Document 2P(d): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Perinatal (form and instructions) Document 2P(e): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Non-Perinatal (form and instructions) Document 2P(f): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Perinatal (form and instructions) Document 2P(g): Drug Medi-Cal Cost Report Forms – Residential – Perinatal (form and instructions) Document 2P(h): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Non-Perinatal (form and instructions) Document 2P(i): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Perinatal (form and instructions) Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3O: Quarterly Federal Financial Management Report (QFFMR) 2014-15 xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/SUD_Forms.aspx Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 xxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality AgreementAgreement Program Specifications

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1A: Title 45, Code of Federal Regulations 96, Subparts C and L, Substance Abuse Prevention and Treatment Block Grant Requirements xxxxx://xxx.xxx.xxx/fdsys/granule/CFR-2005-title45-vol1/CFR-2005- title45-vol1-part96 Document 1B: Title 42, Code of Federal Regulations, Charitable Choice Regulations xxxxx://xxx.xxx.xxxxxxx.xxx/cfr/text/42/part-54 Document 1C: Driving-Under-the-Influence Program Requirements Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J1G: Attachment Y of the DMCPerinatal Services Network Guidelines 2016 Document 1H(a): Service Code Descriptions Document 1J(a): Non-ODS Special Terms and Conditions Drug Medi-Cal Audit Appeals Process Document 1J(b): DMC Audit Appeals Process Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1T: CalOMS Prevention Data Quality Standards Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2C: Title 22, California Code of Regulations xxxx://xxx.xxx.xx.xxx Document 2E: Drug Medi-Cal Certification Standards for Substance Abuse Clinics (Updated July 1, 2004) xxxx://xxx.xxxx.xx.xxx/services/adp/Documents/DMCA_Drug_Medi- Cal_Certification_Standards.pdf Document 2F: Standards for Drug Treatment Programs (October 21, 1981) xxxx://xxx.xxxx.xx.xxx/services/adp/Documents/DMCA_Standards_for_ Drug_Treatment_Programs.pdf Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/Info%20Notice%2020 15/DMC_Billing_Manual%20FINAL.pdf Document 2K: Multiple Billing Override Certification (MC 6700) Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMCDrug Medi-ODS Cal Cost Report Excel Workbook Forms – Intensive Outpatient Treatment – Non-Perinatal (form and instructions) Document 2P(b): Drug Medi-Cal Cost Report Forms – Intensive Outpatient Treatment – Perinatal (form and instructions) Document 2P(c): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Non-Perinatal (form and instructions) Document 2P(d): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Perinatal (form and instructions) Document 2P(e): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Non-Perinatal (form and instructions) Document 2P(f): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Perinatal (form and instructions) Document 2P(g): Drug Medi-Cal Cost Report Forms – Residential – Perinatal (form and instructions) Document 2P(h): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Non-Perinatal (form and instructions) Document 2P(i): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Perinatal (form and instructions) Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3O: Quarterly Federal Financial Management Report (QFFMR) 2014-15 xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/SUD_Forms.aspx Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 xxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 xxxxx://xxxxxxxxxxxxxx.xxx.xxx/omh/browse.aspx?lvl=2&lvlid=53 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 xxxxx://xxxxxxxxxxxxxx.xxx.xxx/omh/browse.aspx?lvl=2&lvlid=53 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality AgreementAgreement Exhibit A, Attachment I A1 Program Specifications

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1A: Title 45, Code of Federal Regulations 96, Subparts C and L, Substance Abuse Prevention and Treatment Block Grant Requirements xxxxx://xxx.xxx.xxx/fdsys/granule/CFR-2005-title45-vol1/CFR-2005­ title45-vol1-part96 Document 1B: Title 42, Code of Federal Regulations, Charitable Choice Regulations xxxxx://xxx.xxx.xxxxxxx.xxx/cfr/text/42/part-54 Document 1C: Driving-Under-the-Influence Program Requirements Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J1G: Attachment Y of the DMCPerinatal Services Network Guidelines 2016 Document 1H(a): Service Code Descriptions Document 1J(a): Non-ODS Special Terms and Conditions Drug Medi-Cal Audit Appeals Process Document 1J(b): DMC Audit Appeals Process Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1T: CalOMS Prevention Data Quality Standards Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2C: Title 22, California Code of Regulations xxxx://xxx.xxx.xx.xxx Document 2E: Drug Medi-Cal Certification Standards for Substance Abuse Clinics (Updated July 1, 2004) xxxx://xxx.xxxx.xx.xxx/services/adp/Documents/DMCA_Drug_Medi­ Cal_Certification_Standards.pdf Document 2F: Standards for Drug Treatment Programs (October 21, 1981) xxxx://xxx.xxxx.xx.xxx/services/adp/Documents/DMCA_Standards_for_ Drug_Treatment_Programs.pdf Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/Info%20Notice%2020 15/DMC_Billing_Manual%20FINAL.pdf Document 2K: Multiple Billing Override Certification (MC 6700) Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMCDrug Medi-ODS Cal Cost Report Excel Workbook Forms – Intensive Outpatient Treatment – Non-Perinatal (form and instructions) Document 2P(b): Drug Medi-Cal Cost Report Forms – Intensive Outpatient Treatment – Perinatal (form and instructions) Document 2P(c): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Non-Perinatal (form and instructions) Document 2P(d): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Perinatal (form and instructions) Document 2P(e): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Non-Perinatal (form and instructions) Document 2P(f): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Perinatal (form and instructions) Document 2P(g): Drug Medi-Cal Cost Report Forms – Residential – Perinatal (form and instructions) Document 2P(h): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Non-Perinatal (form and instructions) Document 2P(i): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Perinatal (form and instructions) Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3O: Quarterly Federal Financial Management Report (QFFMR) 2014-15 xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/SUD_Forms.aspx Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 xxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality AgreementAgreement Program Specifications

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality AgreementAgreement Exhibit A, Attachment I Program Specifications

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality AgreementExpenses

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1A: Title 45, Code of Federal Regulations 96, Subparts C and L, Substance Abuse Prevention and Treatment Block Grant Requirements xxxxx://xxx.xxx.xxx/fdsys/granule/CFR-2005-title45-vol1/CFR-2005- title45-vol1-part96 Document 1B: Title 42, Code of Federal Regulations, Charitable Choice Regulations xxxxx://xxx.xxx.xxxxxxx.xxx/cfr/text/42/part-54 Document 1C: Driving-Under-the-Influence Program Requirements Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J1G: Attachment Y of the DMCPerinatal Services Network Guidelines 2016 Document 1H(a): Service Code Descriptions Document 1J(a): Non-ODS Special Terms and Conditions Drug Medi-Cal Audit Appeals Process Document 1J(b): DMC Audit Appeals Process Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1T: CalOMS Prevention Data Quality Standards Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2C: Title 22, California Code of Regulations xxxx://xxx.xxx.xx.xxx Document 2E: Drug Medi-Cal Certification Standards for Substance Abuse Clinics (Updated July 1, 2004) ODS Waiver Xxxxxxxx Xxxxxx xx Xxxxxxxxx #00-00000 Exhibit A xxxx://xxx.xxxx.xx.xxx/services/adp/Documents/DMCA_Drug_Medi- Cal_Certification_Standards.pdf Document 2F: Standards for Drug Treatment Programs (October 21, 1981) xxxx://xxx.xxxx.xx.xxx/services/adp/Documents/DMCA_Standards_for_ Drug_Treatment_Programs.pdf Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/Info%20Notice%2020 15/DMC_Billing_Manual%20FINAL.pdf Document 2K: Multiple Billing Override Certification (MC 6700) Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMCDrug Medi-ODS Cal Cost Report Excel Workbook Forms – Intensive Outpatient Treatment – Non-Perinatal (form and instructions) Document 2P(b): Drug Medi-Cal Cost Report Forms – Intensive Outpatient Treatment – Perinatal (form and instructions) Document 2P(c): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Non-Perinatal (form and instructions) Document 2P(d): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Perinatal (form and instructions) Document 2P(e): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Non-Perinatal (form and instructions) Document 2P(f): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Perinatal (form and instructions) Document 2P(g): Drug Medi-Cal Cost Report Forms – Residential – Perinatal (form and instructions) Document 2P(h): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Non-Perinatal (form and instructions) Document 2P(i): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Perinatal (form and instructions) Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3O: Quarterly Federal Financial Management Report (QFFMR) 2014-15 xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/SUD_Forms.aspx Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 xxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. The following documents are hereby incorporated by reference into the DMC-ODS Waiver contract though they may not be physically attached to the contract but will be issued in a CD under separate cover: Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (XXXXX) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/XXXXX.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) xxxx://xxx.xxxx.xx.xxx/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines xxxx://xxx.xxxx.xx.xxx/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky x. Xxxxxx, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual xxxx://xxx.xxxx.xx.xxx/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs xxxx://xxx.xxxxxxx.xxx Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors xxxx://xxx.xxxxxxx.xxx Document 3J: CalOMS Treatment Data Collection Guide xxxx://xxx.xxxx.xx.xxx/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards xxxxx://xxxxxxxxxxxxxx.xxx.xxx/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality AgreementAgreement I. Preamble Exhibit A, Attachment I Program Specifications