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Contractor shall adhere to the current schedule of allowable services and rates as <br />referenced in the Policies and Procedures Manual for Title V Maternal and Child Health <br />Services. <br />Total payments will not exceed $10,000.00. <br />SECTION VIII. 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 <br />include: <br />Contractor shall submit: <br />• Title V MCH Prenatal Monthly Aggregate Activity Report, in conjunction <br />with each monthly billing request. Each report shall detail the total <br />unduplicated number of clients seen for the first time within a service <br />category type during the contract period by age, and race/ethnicity. Billing <br />requests will not be processed for payment by DSHS unless accompanied <br />by a complete corresponding aggregate report; <br />• A Request for Advance or Reimbursement Form 270 (Form GC-10), or <br />the form specified in the Contractor's Financial Procedures Manual, no <br />later than sixty (60) days after the end of the contract Attachment term; <br />and, <br />• Other reports as deemed necessary by DSHS, upon reasonable notice to <br />Contractor. <br />General Provisions, Compliance and Reporting Article, Section 1.05 is revised to <br />include: <br />Eligibility: All individuals considered for Title V eligibility must be screened <br />and determined eligible using a DSHS or Title Vprogram-approved screening <br />process as updated in the spring of each year when federal poverty levels and <br />eligibility determination forms are revised. <br />General Provisions, Services Article, Section 2.05, is revised to include: <br />Co-pay: Contractor may assess a co-pay from clients who receive services under <br />this contract Attachment. A co-pay shall not be assessed from such clients if their <br />family income is at or below 100% of the most recently defined federal poverty <br />level. A co-pay assessment may not exceed 25% of the amount DSHS pays <br />Contractor for the provision of a given service, A client shall not be denied <br />services due to inability to pay. <br />PROGRAM ATTACHMENT -Page 3 <br />