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HomeMy WebLinkAboutGrant Related - BOCC (002)Supported Living / Group Home -Exhibit C July 1. 2018 - June 30, 2019 Revision #: 190201 Grant Inw_,rated Services 1763-95588 1 I 519119 13 Contractor Name 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. .- Tom Taylor, BOCC ChairIZ,pfr Contractor Signature Date Signed DSHS Regional Admi strator or Designee Date Signed u 6. C d r. A'. h '1. k I- a p-. qi , I , ''w'. • ' Eragrmrt ,n,' - Providor Pt to 'I - ', cltent Nama CI)ant'P11D Roo -. . Etfactive Dat jSS. Tlar' ate " ISS dally 'Tidy Ralo pro t Sv¢ HmPCD --1' Prof Sva Hrly Rata'H[s 1 Prot sys PCD -.:2 Pros 9v¢ Hrly Rate -2. ISS Prof, Sva Dally -•I Rato.�: . ' - ;ISS SS CM T1er Rate Hold HarMos -aRat, oral lSS .'Dally i'Rato - Admin Tler to Admin Haid Admin 'CRST of Rato'RaiII. �' - Tramp• Othor' Non4SS Rater Total Men -l, ISS DallyyN •Rt to.�,•:4.I E - . � .PI, F. M7SA716- ar7-n,v:u 2-1,12sat IMIT71 ro„v; m.nl�aPl ? c142.44 0.00 SOA(] gryj -[L(v.) $0.00 $2.63 S15-57 5153JA 51336 5225 SO.66 Siito ?n.Ix1 $412791 W 3 190.11- r.F.,.9r [•rn.rwrv. ]A a wrl[,InNl A (]nn ¢nl9 1 5;3.13 0.00 0.00 U.t10 NO.00 I 50.00 51.021 SI1.57 569.71 119.95 1 5725 - $0.25 543)0 511.Ot) 536.45 -- S%.Ilii 3603 I 2"(1100I - IMAM' 1 ('uUT: n' SA716- j nll:r[-fhit;+?nlv0?AII Ilp)l�,A?±15A glAll^1119 4 $3Afi o3 0.00 511.00 0.00 ."60.(1(1 $(I,OU S5.30 c1357 S1 P,Al $76.4•1 5323 Sl..i3 Sal W) $0.1x1 $44.02 S349-92 '603 1002!301 I II,wr 11C.1Y SA71 f nlu�•(' ,raa TA,nt?An Uvn!ifiN97•N 61,1111+n v I SSi.12 gtxl SO.OQ QAO SII,OU So.txi .SIA2 S13S7 569.71 $19.95 53.25 $U'5 Sl -(x) :0,110 S26.4i 9,'176.16 3603 190300 (F,Kr t'l11 r1(r% - SA71 G- Ou:rr-r1.11;< >nAln'•+oI uunnrr,9lwA OSlIJ:�I,P7 1 521(,9 0,00 SO.DO O.W 50.00 SO.UO 54,116 S1 S7 037.53 i3 . S'25 $1,021 5:5.00 50.00 43.-10 515 93 36 3 190201 I ipANT (, Oran' - S t716- uu:a nor, ?nUul'S01 tW4•m,I,IWA n1,7nnpp) 1219.1) 0110 R).00 (1.110 SUAO SOHO SJ.06 51357 SA7.51 535.13 $'?5 SIM2 54.110 50.00 542.40 5379.93 3603 190200 1 ivw n-1 (1 H:Irl1'I nll!1'[,lnitt ±ronn r>In IMIN14DWA 1131.41)9 I 55512 0.00 $).110 I 0.0n So.()o S0.0U SLIP SI357 569.71 $19.95 S=3 $U:Z- 17.1.00 S0.I10 -,764' Saw 16 SA71(,- 6 - 1903-OOi r.Fnra rurvn'- aPIVI',is 111(111?all I0115991MW. (1611aI019 3 $214.9 0.00 5(1.00 0.($1 SOM) Will) $4.06 51357 5237.53 USA3 51.:.5 SI.U2 11.00 Slim 54140 527003 SA71L 3603 190'_01 11X611 t'ot+Tv Mkk-n,RC 2(11110+tl11 IMlM.-I 1WA nVIX-14 k 5 5358.44 0.[x1 50.00 WKI 50.00 in 00 SG fi'_' U1571$371.01 Sill,l' ti1.GG -1 t S ,10 C-19.03 S4 SA716- ;n03 ICCI'01 Grant Integrated Services Revision #:190201 Page 1 of 2 a b c-=. d e f q h i I k I m n :: o '. p q r s t u v w x Rate ISS Prof Svs Prof Svs I I Prof Svs Prof Svs ISS Prof ISS Hold Total ISS Admin r Admin Other Total Non. Total P1 Program Provider Effective Tier ISS Dally Hrs PCD Hrly Rate Hrs PCD Hrly Rate Svs Daily ISS CRST Harmles Daily Admin Hold CRST Transp. Non -ISS ISS Daily Daily Service Name P1 ID Client Name Client Pt ID Date Rate Tier Rate 1 1 2 2 - Rate Tier Rate s Rater Rate < Tier Rate Tier Rate Rate :.Rates: Rate Rate Revision GRANT SA716- COUNTY- DIRECTIONs 1200012501 100807715WA 01/01/2019 4 $286.93 0.00 $0.00 0.00 $0.00 $0.00 $5.30 $13.57 $305.80 $36.44 $2.25 $1.33 $4.00 $0.00 $44.02 $349.82 3603 190200 GRANT SA716- COUNTY- DIRECTIONs 200012501 100859024WA 01/01/2019 5 $358.44 0.00 $0.00 0.00 $0.00 $0.00 $6.62 $13.57 $378.63 $40.12 $2.25 $1.66 $5.00 $0.00 $49.03 $427.66 3603 190200 GRANT SA716- COUNTY - DIRECTIONs 200012501 101158242WA 01/01/2019 2 $142.44 0.00 $0.00 0.00 $0.00 $0.00 $2.63 $13.57 $158.64 $33.36 $2.25 $0.66 $4.00 $0.00 $40.27 $198.91 3603 190200 GRANT SA716- 1 COUNTY- DIRECTIONs 200012501 102327903WA 01/01/2019 3 $219.9 0.00 $0.00 0.00 $0.00 $0.00 $4.06 $13.57 $237.53 $35.13 1 $2.25 $1.02 $4.00 $0.00 $42.40 1 $279.93 3603 190200 Grant Integrated Services Revision #: 190201 Page 2 of 2