07-L(1) Health Contract - Laserfiche WebLink

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demonstrated only by submission of acceptable fam~ly planning claims for services provided to Title V eligible clients which exceeos PERFORMING AGENCY'S Attachment amount by the total program income amounlt. General Provisions, Reports Article, is revised to include: PERFORMING AGENCY shall submit: ' • A Request for Advance or Reimbursement Fotm 270 (TDH Form GG10), no later than ninety (90) days after the end of the attachment term; and, • Other reports as deemed necessary by RECEIVIING AGENCY upon reasonable notice to PERFORMING AGENCY. ' In addition to the site visits authorized by the Inspections A icle of the General Provisions, PERFORMING AGENCY shall allow RECEIVING AGE CY to conduct on-site quality assurance reviews as deemed necessary by RECEIVING A ENCY. Unsatisfactory review findings may result in implementation of General Provisions, Sa'pctions Article. I 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 AGEN~Y officer, director, agent or managing employee (e.g, general manager, business manager,~ administrator, director, or like individual who exercises operational or managerial control ov~r PERFORMING AGENCY or who directly or indirectly conducts the day-to-day business of th~ PERFORMING AGENCY), is an entity or individual who: • Has been convicted of any offense under 42 U.S.C. § 132pa-7(b)(1)-(3); ~ Has had a civil monetary penalty assessed under 42 U.S.C. § 1320a andlor 42 U.S.C. § 1320a-8; or, I~ Has been excluded from ParticiPation in a Program und r 42 U.S.C. 1395 et se ~ § q.; or under a State health care program. , If the foregoing statement is not true, PERFORMINGI 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 mrisrepresentation. PHARMACY ' If PERFORMING AGENCY is dis ensin p g and/or providing pre cnbed 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, Chapt r 560, or shall dispense and/or provide such medications in compliance with other pharmacy statutes with prior approval from RECENING AGENCY. ATTACHMENT - Page 4