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Home My WebLink About*Other - Renew/7 K21-013 Supported Living I Group Home -Exhibit C July 1, 2020 - June 30, 2021 Revision #: 210400 GRANT COUNTY - 01 200012501 1963-57191 1N 12/31/20 12 Contractor Name Provider P1 ID Contract No. Region Process Date No. of Clients (excluding SSP funded) The un ned hereby affirm that the Ilowing are the agreed upon number of clients and reimbursement rates associated with the indicated contract and contract period. This rat het re ' ion s persed all previ rate sheets as of the effective date. Co act ign re Date Signed DSHS Regional Administrator or Designee Date Signed ' e ' d c - .'-A' f 9 S'F i"-, k':� '_1Ih- ao o u +z.'v :k ' ISS''. r -Prof Sva ProfSva '-' Prof 9Js 153 Prof �. ."-. Temp Admin = ONwr Tota., Total'P4Servke program -� -� Rata Effective Tier ISS Daily Hn PCD Hrly Rate Prof Svs Hrly Rate Sve Daily ISS CRST Total ISS Admin ', Rab CRST c.rt i Tran`ap. Noii-ISS NoreJS$ Daily - CoMBAC CINId Nama :Cliara P110 5' ' Date' `- Laval Tier Rate ''T1 `` 1'" ` Hm PCO2 2 Rata' Tier Rate ai - Tier�Rab Adust YRat 'Rate "- Rate "Retea Dail Rete "- n.w.be- GRANT SA716- COUNTY - DIRECTIONS 100195167WA 01/01/2021 I $63.69 0.00 $0.00 0.00 $0.00 $0.00 $1.18 $64.87 $23.05 510.76 $0.29 $2.40 $4.61 $0.00 $41.11 5105.98 3603 210400 GRANT SA716- COUNTY- DIRECTIONS I 100325622WA 01/01/2021 1 4 1 $331.53 0.00 $0.001 0.00 $0.00 1 $0.00 1 $6.13 $337.66 $42.10 54188 1 $1.54 $2.40 &4.61 1 $0.001 594.53 $432.191 3603 1 210400 GRANT SA716- COUNn' - DIRECTIONS 100388693WA 01/01/2021 1 3.69 0.00 $0.00 0.00 $0.00 $0.00 $1.18 $64.87 $23.05 1111.76 $0.29 $2.40 $4.61 $0.00 $41.11 5105.98 3603 210400 GRANT SA716- COUNTY - D TI N 100420644WA 01/01/2021 5 $414.15 0.00 $0.00 0.00 $0.00 $0.00 $7.65 $421.80 $46.36 553.91 $1.91 $2.40 $4.61 $0.00 $109.19 $530.99 3603 210400 GRANT SA716- COUNTY- URECTIDN$ I 100460423WA 01/01/2021 1 1 1 $63.69 0.001 $0.00 0.00 I $0.00 1 $0.00 $1.18 1 $64.87 $23.05 510.76 $0.29 1 $2.40 I $4.61 $0.001 s4i.111 $105.98 3603 1 210400 GRANT SA716- COUNTY - DIRECTIONS 100598316WA 01/01/2021 5 $414.15 0.00 $0.00 0.00 $0.00 $0.00 $7.65 $421.80 1 $46.36 553.91 1.91 $2.40177$00.0000 S109.19 1530.99 3603 210400 GRANT SA716- COUNn' - DIRECTIONS 100783401WA 01/01/2021 3 $254.08 0.00 $0.00 0.00 $0.00 $0.00 $4.69 $258.77 $40.59 $34.88 $1.18 $2.40 184.82 534159 3603 210400 GRAM SA716- COUNT - DIRECTIGNI 100807715WA 01/01/2021 4 $331.53 0.00 $0.00 0.00 $0.00 $0.00 $6.13 $337.66 $42.10 543.88 $1'54 51.40 $94.53 5432.19 3603 210400 GRACOUNTY- SA716- DIwNt o1RE n 100859024WA 01/01/2021 5 $414.15 0.00 $0.00 0.00 $0.00 $0.00 $7.65 $421.80 $46.36 ssa.o4 $1.91 $2.40 $110.48 5532.28 3603 210400 GRANT COUNTY - 01 Revision #: 210400 V Page 1 of 2 GRANT COUNTY - 01 Revision #: 210400 Page 2 of 2 b f -h I. LL.-`J �- J,W �p q qISSProgram L U V 'Prof'!' pr6ftl Pi�fSve IS Tamp T Total P1 S. rv� _ Rafe EReetfve liarbftr ISS "PCD Hrlyltate ProfProfivs 1-14kais ISS 6iiii i 'isil Adiiiri" � CRST Cott Tramp. Nor�133 tiorkSs Daily CodatRAC N.- client NameCheit PI ID Vate Level Tier Rt. I I Hrs PCD 2 2 Tier Raft DA, R.WTI., Rate Adlust ner Rah Rate Rate Rat" Daily Rate Revisloall GRANT SA716- COUNTY- OUNTY-DIRECTIONS DIRECTIONS 100867261 WA 01/01/2021 3 $254.08 0.00 $0.00 0.00 S0.00 S0.00 $4.69 $258.77 $40.59 $34.75 $1.18 $2.40 $4.61 50.00 583.53 $342.30. 3603 210400 GRANT SA716- COUNTY - DIRECTIONS 101 158242WA 01/01/2021 2 $164.58 0.00 $0.00 0.00 $0.00 $0.00 $3.04 $167.62 $38.54 524.17 $0.76 $240 $4.61 $0.00 $70.48 5238.10 3603 1 210400 1 � � � � � SA716 COUNTY- DIRECTIONS 102327903WA 01/01/2021 3 $254.08 0.00 S0.00 0.00 $0.00 $0.00 $4.69 $258.771 $40.59 S34.751 $1.1 S0.00 59153 $342.30 3603 210400 GRANT COUNTY - 01 Revision #: 210400 Page 2 of 2