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Agreements/Contracts - GRIS
4) K2Ip_036 44 Supported Living / Group Home -Exhibit C July 1, 2019 - June 30, 2020 Grant Integrated Services 200012501 1963-57191 1N 12/30/19 k1___ PrnvidPr P1 ID Contract No. Region Process Date Revision #: 200200 14 No. of Clients (excluding SSP funded) The undersigned hereby affirm that the following are the agreed upon number of clients and reimbursement rates associated with the indicated contract and contract period. This I rate sheet revision supersedes all previous rate sheets as of the effective date. 17-49 Contractor Signature Date Signed DSHS Regional Administrator or Designee Date Signed a b c d e f g h I k I m n 0 p q r s t u v w x Program Rate Effective ISS Tler ISS Dally Prof Svs Prof Svs Hrly Rate Prof Svs Prof Svs Hrly Rate ISS Prof Svs Daily ISS CRST ISS Hold Harmles Total ISS Daily Admin Admin Hold Admin CRST TierE$2.36 Transp. Other Non- Total Non -ISS Total Daily P1 Service Revision # Name Client Name Client P1 ID Date Rate Tier Rate Hrs PCD 1 1 Hrs PCD 2 2 Rate Tier Rate s Rate Rate Tier Rate Rate Rate ISS Dail Rate GRANT SA716- COUNTY- DIRECTIONS 100077092WA 01/01/2020 2 $161.67 0.00 $0.00 0.00 $0.00 $0.00 $2.99 $11.36 $176.02 $37.86 $2.25 $0.75 $5.68 $0.00 $48.90 $224.92 3603 200200, GRANT SA716- COUNTY - DIRECTIONS 100195167WA 01/01/2020 l $62.56 0.00 $0.00 0.00 $0.00 $0.00 $1.16 $11.36 $75.08 $22.64 $2.25 $0.28 $2.36 $4.54 $0.00 $32.07 $107.15 3603 200200 GRANT SA716- COUNTY - DIRECTIONS 100325622WA 01/01/2020 4 1 $325.67 0.00 $0.00 0.00 $0.00 $0.00 $6.02 $11.36 $343.05 $41.36 $2.25 $1.51 $2.36 $4.54 $0.00 $52.02 $395.07 3603 200200. GRANT SA716- COUNTY - DIRECTIONS 100388693WA 01/01/2020 1 $62.56 0.00 $0.00 0.00 $0.00 $0.00 $1.16 $11.36 $75.08 $22.64 $2.25 $0.28 $2.36 $4.54 $0.00 $32.07 $]07.15 3603 20 GRANT SA716- - COUNTY200200. DIRECTIONS 100388695WA 01/01/2020 3 $249.59 0.00 $0.00 0.00 $0.00 $0.00 $4.61 $11.36 $265.56 $39.87 $2.25 $1.16 $2.36 $5.68 $0.00 $51.32 $316.88 3603 GRANT SA716- COUNTY- DIRECTIONS 100420644WA 01/01/2020 3 $249.59 0.00 $0.00 0.00 $0.00 $0.00 $4.61 $11.36 $265.56 $39.87 $2.25 $1.16 $2.36 $4.54 $0.00 $50.18 $315.74 3603 2002001 GRANT SA716- COUNTY - COUNTI - 100460423WA 01/01/2020 1 $62.56 0.00 $0.00 0.00 $0.00 $0.00 $1.16 $11.36 $75.08 $22.64 $2.25 $0.28 $2.36 $4.54 $0.00 $32.07 $107.15 3603 0200 -DIRECTGRANT SA716- 1200200 COUNTY- DIRECTIONS 100598316WA 01/01/2020 3 $249.59 0.00 $0.00 0.00 $0.00 $0.00 $4.61 $11.36L$265.56 $39.87 $2.25 $1.16 1 $2.36 $4.54 $0.00 $50.18 $315.74 3603 GRANT 1$265.56 SA716- COUNTY- DIRECTI NS 10078340IWA 01/01/2020 3 $249.59 1 0.00 $0.00 0.00 $0.00 $0.00 $4.61 1 $11.36 1 $39.87 $2.25 $1.16 2.36 $5.68 $0.00 $51.32 $316.88 3603 20 Grant Integrated Services Revision #: 200200 Page 1 of 2 a b c d e f 9 h- i.. k I m' -n. - o 'p q r s t u v w I x Program Name Client Name Client P1 ID Rate Effective Date ISS Tier Rate ISS Daily Tier Rate Prof Svs Hrs PCD 1 ProfSvs Hrly Rate 1 Prof Svs Hrs PCD 2 Prof Svs Hrly Rate 2 ISS Prof Svs Daily Rate ISS CRST Tier Rate ISS Hold Harmles s Rate Total ISS Daily Rate Admin Tier Rate Admin Hold Admin CRST Tier Rate Cert Rate Transp. Rate Other Non- ISS Total Non -ISS Daily Total Daily Rate P1 Service Revision g GRANT COUNTY- DIRECTIONS 100807715WA 01/01/2020 4 $325.67 0.00 $0.00 0.00 $0.00 $0.00 $6.02 $11.36 $343.05 $41.36 $2.25 $1.51 $2.36 $4.54 $0.00 $52.02 $395.07 SA716- 3603 200200 GRANT COUNTY- DIRECTIONS 100859024WA 01/01/2020 5 $406.83 0.00 $0.00 0.00 $0.00 $0.00 $7.51 $11.36 $425.70 $45.54 $2.25 $1.88 $2.36 $5.68 $0.00 $57.71 $483.41 SA716- 3603 200200 GRANT COUNTY- DIRECTIONS 100867261WA 01/01/2020 3 $249.59 0.00 $0.00 0.00 $0.00 $0.00 $4.61 $11.36 1$265.56 $39.87 $2.25 $1.16 $2.36 $4.54 $0.00 $50.18 $315.74 SA716- 1 3603 200200 GRANT 1$176.02 COUNTY- DIRECTIONS 101 158242W 01/01/2020 2 $161.67 0.00 $0.00 0.00 $0.00 $0.00 $2.99 $11.36 $37.86 $2.25 $0.75 $2.36 $4.54 $0.00 $47.76 $223.78 SA716- 3603 200200 GRANT COUNTY- DIRECTIONS 102327903WA 01/01/2020 3 $249.59 0.00 $0.00 0.001. $0.00 $0.00 $4.61 $11.36 $265.56 $39.87 $2.25 $1.16 $2.36 $4.54 $0.00$50.18 $315.74 SA716- 3603 200200 Grant Integrated Services Revision #: 200200 Page 2 of 2