07-L(1) Health Contract - Laserfiche WebLink

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demonstrated only by submission of acceptable family planning claims for services provided to Title V eligible clients which exceeds PERFORMING AGENCY'S Attachment amount by the total program income amount. General Provisions, Reports Article, is revised to include: PERFORMING AGENCY shall submit: • A Request for Advance or Reimbursement Form 270 (TDH Form GC-10), no later than ninety (90) days after the end of the attachment term; and, • Other reports as deemed necessary by RECEIVING AGENCY upon reasonable notice to PERFORMING AGENCY. In addition to the site visits authorized by the Inspections Article of the General Provisions, PERFORMING AGENCY shall allow RECEIVING AGENCY to conduct on-site quality assurance reviews as deemed necessary by RECEIVING AGENCY. Unsatisfactory review findings may result in implementation of General Provisions, Sanctions Article. PERFORMING AGENCY certifies that neither the PERFORMING AGENCY nor any individual who has a direct or indirect ownership or controlling interest of 5°Io or more of the PERFORMING AGENCY nor any PERFORMING AGENCY officer, director, agent or managing employee (e.g. general manager, business manager, administrator, director, or like individual who exercises operational or managerial control over PERFORMING AGENCY or who directly or indirectly conducts the day-to-day business of the PERFORMING AGENCY), is an entity or individual who: • Has been convicted of any offense under 42 U.S.C. § 1320a-7(b)(1)-(3); • Has had a civil monetary penalty assessed under 42 U.S.C. § 1320a and/or 42 U.S.C. § 1320a-8; or, • Has been excluded itom participation in a program under 42 U.S.C. § 1395 et seq.; or under a State health care program. If the foregoing statement is not true, PERFORMING AGENCY shall submit a disclosure/ownership form to RECEIVING AGENCY. PERFORMING AGENCY shall immediately notify the RECEIVING AGENCY in writing, in the event that the foregoing statement changes during the term of this Attachment. A false statement regarding PERFORMING AGENCY'S status will be treated as a material misrepresentation. PHARMACY If PERFORMING AGENCY is dispensing and/or providing prescribed medications, e.g., birth control pills, antibiotics, etc., on site, it shall have, at a minimum, a Class D pharmacy license as provided by the Texas Pharmacy Act, Occupations Code, Chapter 560, or shall dispense and/or provide such medications in compliance with other pharmacy statutes with prior approval from RECENING AGENCY. ATTACHMENT - Page 4