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Supported Living / Group Home -Exhibit C July 1, 2020 - June 30, 2021 Revision #: 210200
Grant County 200012501 1963-57191 1N 7/30/20 13
Contractor Name Provider P1 ID Contract No. Region Process Date 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.
Date Signed
DSHS Regional Administrator or Designee
Date Signed
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Rate
Prof Svs
Prof Svs
ISS Prof
ISS Hold
Total ISS
Admin
Admin
Other
Total
Total
P1
Program
Effective
ISS Tier
ISS Daily
Prof Svs
Hrly Rate
Prof Svs
Hrly Rate
Svs Daily
ISS CRST
Harmles
Daily
Admin
Hold
CRST Tier
Cert
Transp.
Non-
Non -ISS
Daily
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
Rate
ISS
Daily
Rate
#
GRANT
SA716-
COUNTY-
DIRECTIONS
100195167WA
08/01/2020
1
$62.56
0.00
$0.00
0.00
$0.00
$0.00
$1.16
$0.00
$63.72
$22.64
$16.84
$0.28
$2.40
$4.54
$0.00
$46.70 1
$110.42
3603
210200
GRANT
SA716-
COUNTY -
DIRECTIONS
100325622WA
08/01/2020
4
$325.67
0.00
$0.00
0.00
$0.00
$0.00
$6.02
$0.00
$331.69
$41.36
$68.67
$1.51
$2.40
$4.54
$0.00
$118.48
$450.17
3603
210200
GRANT
SA716-
COUNTY-
DIRECTIONS
100388693WA
08/01/2020
1
$62.56
0.00
$0.00
0.00
$0.00
$0.00
$1.16
$0.00
$63.72
$22.64
$16.84
$0.28
$2.40
$4.54
$0.00
$46.70
$110.42
3603
210200
GRANT
SA716-
COUNTY-
DIRECTIONS
100388695WA
08/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$0.00
$254.20
$39.87
$54.60
$1.16
$2.40
$5.68
$0.00
$103.71
$357.91
3603
210200
GRANT
SA716-
COUNTY-
DIRECTIONS
100420644WA
08/01/2020
5
$406.83
0.00
$0.00
0.00
$0.00
$0.00
$7.51
$0.00
$414.34
$45.54
$84.37
$1.88
$2.40
$4.54
$0.00
$138.73
$553.07
3603
210200
GRANT
SA716-
COUNTY-
DIRECTIONS
100460423WA
08/01/2020
1
$62.56
0.00
$0.00
0.00
$0.00
$0.00
$1.16
$0.00
$63.72
$22.64
$16.84
$0.28
$2.40
$4.54
$0.00
$46.70
$110.42
3603
210200
GRANT
SA716-
COUNTY-
DIRECTIONS
100598316WA
08/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$0.00
$254.20
$39.87
$54.39
$1.16
$2.40
$4.54
$0.00
$102.36
$356.56
3603
210200
GRANT
SA716-
COUNTY-
DIRECTIONS
100783401WA
08/01/2020
3
249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$0.00
$254.20
$39.87
$54.60
$1.16
$2.40
$5.68
$0.00
$103.71
$357.91
3603
210200
GRANT
SA716-
COUNTY -
DIRECTIONS
100807715WA
08/01/2020
4
$325.67
0.00
$0.00
0.00
$0.00
$0.00
$6.02
$0.00
331.69
1.36
68.67
1.51
$2.40
$4.54
$0.00
$118.48
$450.17
3603
210200
Grant County
Revision #: 210200
AUG 12 2U2
Page 1 of 2
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o
p
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t
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w I
x
Rate
Prof Svs
Prof Svs
ISS Prof
ISS Hold
Total ISS
Admin
Admin
Other
Total
Total
P1
Program
Effective
ISS Tier
ISS Daily
Prof Svs
Hrly Rate
Prof Svs
Hrly Rate
Svs Daily
ISS CRST
Harmles
Daily
Admin
Hold
CRST Tier
Cert
Transp.
Non-
Non -ISS
Daily
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
Rate
ISS
Daily
Rate
#
GRANT
SA716-
COUNTY-
DIBECT1oNS
100859024WA
08/01/2020
1 5
$406.83
0.00
$0.00
0.00
$0.00
$0.00
$7.51
$0.00
$414.34
$45.54
$84.57
$1.88
$2.40
$5.68
$0.00
1$140.07
1 $554.41
3603
210200
GRANT
1$102.36
$A716-
COUNTY -
DIRECTIONS
100867261WA
08/01/2020
3
$249.59
0.00
$0.00
0.00
0.00
.00
$4.61
$0.00
$254.20
$39.87
$54.39
$1.16
$2.40
$4.54
$0.00
356.56
3603
210200
GRANT
SA716-
COUNTY -
DIRECTIONS
n
Ioss242wA
O8/ot/2020
2
$161.67
0.00
S0 0
0.00
$0.00
$0.00
$2.99
$0.00
$164.66
$37.86
$37.84
0.75
$2.40
$4.54
$0.00
$83.39
$248.05
3603
210200
GRANT
SA716-
1
1210200
COUNTY-
DIRECTIONS
102327903WA
08/01/2020
1 3
1 $249.591
0.001
$0.0010.001
$0.001$0.001
$4.61
$0.00
$254.20
$39.87
$54.39
$1.16
$2.40
$4.54
$0.00
$102.36
$356.56
3603
Grant County Revision #: 210200 Page 2 of 2