SIGNATURES TO FOLLOW ON NEXT PAGE Sample Clauses

SIGNATURES TO FOLLOW ON NEXT PAGE. WHEREFORE, intending to be legally bound, the parties hereto have executed this Agreement as of the date set forth below. “PAYOR ” By:______________________________________ Print: ____________________________________ Its: Chief Executive Officer Date: ____________________________________ “PROVIDER” By: ______________________________________ Print: _____________________________________ Its: ______________________________________ Date: ____________________________________ Attachment A - ACRONYM AND GLOSSARY DEFINITIONS Agreement: Means this Agreement whereby PAYOR(s) purchase services on a subcontracted basis from the party designated as the "PROVIDER" in the introductory paragraph of this Agreement.
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SIGNATURES TO FOLLOW ON NEXT PAGE. WHEREFORE, intending to be legally bound, the parties hereto have executed this Agreement as of the date set forth below. “BABHA” BAY-ARENAC BEHAVIORAL HEALTH AUTHORITY By: Xxxxxxxxxxx Xxxxxx Its: Chief Executive Officer Date: By: Xxxxxxx Xxxxx Its: Board Chairperson Date: “Provider” [NAME OF PROVIDER] By: Print: Its: Date: Attachments: Statement of Work Exhibit A: BABHA Recipient Rights List of Policies and Attestation Exhibit B: Provider Disclosures Exhibit C: Provider Training Requirements Exhibit D: Credentialing and Re-Credentialing Requirements AS APPLICABLE (Primary and Ancillary providers) STATEMENT OF WORK EXHIBIT A
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SIGNATURES TO FOLLOW ON NEXT PAGE. WHEREFORE, intending to be legally bound, the parties hereto have executed this Agreement as of the date set forth below. “PAYOR ” By: Print: Its: Chief Executive Officer Date: “PROVIDER” By: Print: Its: Date: Attachment A - ACRONYM AND GLOSSARY DEFINITIONS Agreement: Means this Agreement whereby PAYOR(s) purchase services on a subcontracted basis from the party designated as the "PROVIDER" in the introductory paragraph of this Agreement.
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SIGNATURES TO FOLLOW ON NEXT PAGE. WHEREFORE, intending to be legally bound, the parties hereto have executed this Agreement as of the date set forth below.
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SIGNATURES TO FOLLOW ON NEXT PAGE. WHEREFORE, intending to be legally bound, the parties hereto have executed this Agreement as of the date set forth below. PAYOR: [CMHSP Name] NAME, TITLE Date WITNESSED BY: Date PROVIDER: Date WITNESSED BY: Date Attachment A – Statement of Work <INSERT PROVIDER NAME> <INSERT FISCAL YEAR> I. TARGET SERVICE GROUP AND ELIGIBILITY CRITERIA FOR SERVICES: Commented [BG38]: Authorization now occurs outside of the WSA and CMHSPs don't have to wait for approval from MSHN or MDHHS to get services started. Commented [AD39R38]: Removed. Commented [AD40]: X. Xxxxxxx- Per TAPS: ● The first sentence refers to where Treatment is delivered. Please see Section 6 of the BACB Practice Guidelines for Healthcare Funders which refers to Location Where Treatment is Delivered and states that it “may be delivered in a variety of settings, including residential treatment facilities, inpatient and outpatient programs, homes, schools, transportation, and places in the community.” We have had Family Guidance workers go with children to their dentist office or taken children in the community to practice skills and this is a critical component to generalize therapeutic benefits. ● The contract developers may wish to look at the wording in the BACB’s document on page 15 (Typical Program Components) regarding what is taught to revise section to be more accurate. ● The Definitions of Focused and Comprehensive Intervention are not correct. According to the BACB (pg. 25 of the attached Practice Guidelines) Focused ABA ranges from 10-25 hours; Comprehensive ABA involves 30-40 hours of ABA. This is not consistent with your Attachment H Glossary and Terms. Commented [KJ41R40]: Additions per MDHHS MPM Section 18.10 pg. 487 (pdf copy) xxxxx://xxx.xxxx.xxxxx.xx.xx/dch- medicaid/manuals/MedicaidProviderManual.pdf Commented [KJ42R40]: PNMC: Agree to changes made Commented [BG43]: Typo Commented [AD44R43]: Deleted. Commented [MS45]: We are no longer designating these levels. Commented [AD46R45]: Recommend not removing this language and keeping the blue tracked changes. This is still a requirement in the Michigan Medicaid Manual (page 488 of PDF). Confirmed with Xxxx Xxxxx and Xxxx Xxxxxx that this requirement has not changed but may in the future. Commented [KJ47R45]: PNMC: Agree to changes made Commented [MS48]: CMHCM does not authorize transportation Commented [AD49R48]: @Xxxx Xxxxx can you please review this? Recommend rejecting suggested changes. Transportation is available and should be authorize...
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SIGNATURES TO FOLLOW ON NEXT PAGE. WHEREFORE, intending to be legally bound, the parties hereto have executed this Agreement as of the date set forth below. “BABHA” BAY-ARENAC BEHAVIORAL HEALTH AUTHORITY By: Xxxxxxxxxxx Xxxxxx Its: Chief Executive Officer Date: By: Xxxxxxx Xxxxx Its: Board Chairperson Date: “Provider” [NAME OF PROVIDER] By: Print: Its: Date: Attachments: Statement of Work Exhibit A: Business Associate Agreement/Qualified Service Organization Agreement Exhibit B: BABHA Recipient Rights List of Policies and Attestation Exhibit C: Provider Disclosures Exhibit D: Provider Training Requirements Exhibit E: Credentialing and Re-Credentialing Requirements AS APPLICABLE (Primary and Ancillary providers) STATEMENT OF WORK EXHIBIT A BUSINESS ASSOCIATE AGREEMENT QUALIFIED SERVICE ORGANIZATION AGREEMENT (Not required for other HIPAA Covered Entities) This Business Associate Agreement/ Qualified Service Organization Agreement ("Agreement") is made and entered into between Bay-Arenac Behavioral Health Authority ("COVERED ENTITY") having its principal place of business at 000 Xxxxxxxxxx, Bay City, MI 48708 and [NAME OF PROVIDER] ("Business Associate" or "BA"), having its principal place of business at [ADDRESS OF PROVIDER]. This BAA states additional terms and conditions to the Principal Agreement between Covered Entity and BA as defined in Section I below.
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SIGNATURES TO FOLLOW ON NEXT PAGE. WHEREFORE, intending to be legally bound, the parties hereto have executed this Agreement as of the date set forth below. PAYOR: [CMHSP Name] NAME, TITLE Date WITNESSED BY: Date PROVIDER: Date WITNESSED BY: Date Attachment A – Statement of Work <INSERT PROVIDER NAME> <INSERT FISCAL YEAR> TARGET SERVICE GROUP AND ELIGIBILITY CRITERIA FOR SERVICES: The target group for the ABA benefit includes consumers from birth through 20 years of age, ending on the 21st birthday with a diagnosis of Autism Spectrum Disorder (ASD) based upon a medical diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) of ASD, who have the developmental capacity to clinically participate in the available interventions covered by the benefit, and who have Medicaid insurance. A well-established DSM-IV diagnosis of Autistic Disorder, Asperger’s Disorder or Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) should be given the diagnosis of ASD. In addition, only consumers who have received an independent needs-based evaluation, plus authorization from Mid-State Health Network and final approval from MDHHS, are eligible to receive ABA.
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