HomeMy WebLinkAboutAgreements/Contracts - GRISSupported Living / Group Home -Exhibit C
July 1, 2020 - June 30, 2021
K20-197
Revision #: 210301
CRAN'r COUNTY - 01 200012501 1963-57191 1N 11/3/20 12
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
rate sheet revision supersedes all previous rate sheets as of the effective date.
j e7� _ [ to ��1�����v`-c � 11/23/20
Contractor Signature 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 Dally
Prof Svs
Hrly Rate
Prof Svs
Hry Rate
Svs Daily
ISS CRST
Harmles
Daily
Admin
Had
CRST Tier
Cert
Transp.
Non-
Non -ISS
Daily
Name
ClientName
Client P1 ID
D
Rats
Tier Rate
Hrs PCD 1
1
Hrs PCD 2
2
Rate'
Tier Rate
s Rata
to `Tier
Rate
Rate °
Rate '
Rate
ISS
Dail
Rate '
Service
Rwislon
a
GRANT
COUNTY-
SA716-
DIRECTIONS.100195167WA
10/01/2020
1
62.56
0.00
$0.00
0.00
$0.00
$0.00
$1.16
$0.00
$63.72
$22.64
$10.76
$0.28
$2.40
$4.54
$0.00
$40.62
$104.34
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
100325622WA
10/01/2020
4
$325.67
0.00
$0.00
0.00
$0.00
$0.00
$6.02
$0.00
5331.69
$41.36
$43.87
$1.51
$2.40
$4.54
$0.00
$93.68
$42537
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
100388693WA
10/01/2020
1
$62.56
0.00
$0.00
0.00
$0.00
$0.W
$1.16
$0.00
$63.72
$22.64
$10.76
$0.28
$2.40
$4.54
$0.00
$40.62
$104.34
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
I
100420644WA
10/01/2020
5
$406.83
0.00
$0.00
0.00
$0.00
$0.00
$7.51
$0.00
$414.34
$45.54
$53.90
$1.88
$2.40
$4.54
0.00
$108.26
$522.60
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
100460423WA
10/0112020
1
$62.56
0.00
$0.00
0.00
$0.00
$0.00
$1.16
$0.00
$63.72
$22.64
$10.76
$0.28
$2.40
$4.54
$0.00
$40.62
$104.34
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
100598316WA
10/23/2020
5
$406.83
0.00
$0.00
0.00
$0.00
$0.00
$7.51
$0.00
$414.34
$45.54
$53.90
$t.88
$2.40
$4.54
$0.00
$108.26
$522.60
3603
210301
GRANT
COUNTY-
SA716-
DIRECTIONS
100783401WA
10/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$0.00 1$254.20
$39.87
$34.88
$1.16
$2.40
$5.681
$0.00
$83.99
$338.19 1
3603
210300
GRANT
COUNTY-
1$331.69
SA716-
DIRECTIONS
100807715WA
10/01/2020 1
4
$325.67
0.001
$0.00
0.00
$0.00
$0.00
$6.02
$0.00
$41.36
$43.87
$1.51
$2.40
$4.54
$0.00.
$93.68
$425.37
3603
210300
GRANT
COUNTY-
SA716-
DIRECrioNS
100859024WA 1
10/01/2020
5
06.83
0.00
$0.00
0.00
$0.00
$0.00
7.51
$0.00$414.34
$54.03
$1.88 1
$2.40
5.68
$523.87
3603
210300
GRANT COUNTY - 01
Revision #: 210301
RECEIVED
NOV - 4 2020
GRANT COUNTY COMMISSIONERS
Page 1 of 2
WA
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x.
Program
Name
Client Name
Client P7 ID
Rate
Effective
Date
ISS Tier
Rate
ISS Daily
Tier Rate
Prof Svs
Hrs PCD 1
Prof Svs
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
ITier Rate
Admin
Hold
Admin
CRST Tier
Rate
Cert
Rate
Transp.
Rate
Other
Non-
ISS
Total
Non -ISS
Daily
Total
Daily
Rate
' P1
Service
Revision
u
GRANT
COUNTY-
DTRECTIONS
100867261WA
10/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$0.00
IS254.20
$39.87
$34.75
$1.16
$2.40
$4.54
$0.00
1 $82.72
$336.92
SA716-
1 3603
210300
GRANT
COUNTY-
DIRECTIONS
1101158242WA
10/01/2020
2
$161.67
0.001
$0.00
0.00
$0.00
$0.00
$2.99
$0.00
1$104.66
$37.86
$24.17
$0.75
$2.40
$4.54
$0.00
$69.72
$234.38
SA716-
3603
210300
GRANT
1102327903WAI10/01/2020
COUNTY-
DIRECTIONS
3
$249.59
0.00
$0.00
0.()OF
$0.00
$0.00
$4.61
$0.00
$254.20
$39.87
1 $34.75
$1.16
$2.40
$4.54
$0.00
$82.72
$336.92
SA716-
3603
210300
GRANT COUNTY - 01 Revision #: 210301 Page 2 of 2