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The fax number for submitting State of Texas Purchase Voucher (Form B-13) to the Claims <br />Processing Unit is (512) 458-7442. The email address is invoices(n~,dshs.state.tx.us. <br />SECTION VII. BUDGET: See attached budget page. <br />SOURCE OF FUNDS: State <br />SECTION II. SPECIAL PROVISIONS: <br />For purposes of this contract Attachment only, the following provisions shall apply: <br />General Provisions, Compliance and Reporting Article, Section 1.03, is revised to include: <br />Contractor shall report to DSHS using established reports directed by the Policy and <br />Procedures Manual for Primary health Care, and other data andlor reports as deemed <br />necessary by DSHS, upon reasonable notice to Contractor. <br />Failure to submit required reports in a timely manner may result in sanctions according to <br />provisions of the contract. <br />General Provisions, Compliance and Reporting Article, Section 1.05 is revised to include: <br />Eligibility: All individuals considered for PHC eligibility must be screened and determined <br />eligible using a DSHS approved screening process as updated in the spring o,f each year when <br />federal poverty levels and eligibility determination forms are revised. <br />General Provisions, Services Article, Section 2.05, is revised to include: <br />Contractor may assess a cost sharing from clients who receive services under this contract <br />Attachment. Cost sharing may not exceed 25 percent of the Contractor's cost for the service. <br />A client shall not be denied services due to inability to pay. <br />Contractor shall make reasonable efforts to investigate and apply for all other sources of third <br />party funding available to, or identified by, the patient before submitting DSHS Program <br />claims for allowable costs. <br />General Provisions, Terms and Conditions of Payment Article, Section 5.04 is replaced with the <br />following: <br />Contractor shall accept reimbursement or payment from DSHS and any applicable fees from <br />clients for clinical health services as payment in full for services or goods provided to clients. <br />Contractor agrees to not seek additional reimbursement or payment for services or goods <br />from clients other than applicable fees for clinical health services. <br />General Provisions, Access and Inspection Article, Section 9.01 is revised to include: <br />PROGRAM ATTACHMENT -Page 3 <br />