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• Has had a civil monetary penalty assessed under 42 U.S.C. § 1320a and/or 42 U.S.C. § <br />1320a-8; or, ' <br />• Has been excluded from participation in a program under 42 U.S.C. § 1395 et seq.; or <br />under a Sfate health care program. ' <br />If the foregoing statement is not true, PERFORMINC AGENCY shall submit a <br />disclosure/ownership form to RECEIVING AGENCY. P$RFORMING AGENCY shall <br />immediately notify the RECENING AGENCY in writing, in the event that the foregoing <br />statement changes during the term of this Attachment. A false statement regarding <br />PERFORMING AGENCY'S status will be treated as a material rl1isrepresentation. <br />PHARMACY <br />If PERFORMING AGENCY is dispensing and/or providing proscribed medications, e.g., birth <br />control pills, antibiotics, etc., on site, it shall have, at a minimum, a Class D pharmacy license as <br />provided by the Texas Pharmacy Act, Occupations Code, Chapqer 560, or shall dispense and/or <br />provide such medications in compliance with other pharmacy sxatutes with prior approval from <br />RECENING AGENCY. ' <br />SECTION III. BUDGET: <br />PERFORMING AGENCY shall adhere to the current schedule of allowable services and rates as <br />referenced in SECTION II. SPECIAL PROVISIONS, as amended and approved by the <br />RECENING AGENCY. ' <br />Total payments will not exceed $20,000.00. <br />F <br />ATTACHVIENT - Page 5 <br />