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HomeMy WebLinkAboutGrant Related - GRISc - Supported living 1 Group Home -Exhibit C July 1, 2018 - June 30, 2019 K 19-080 4-7 Revision #: 190202 Grant luleerated Services 1763-95888 119 615119 14 Contractor Naine 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. 10 n ont t ctor Signature Date Signed IDSHS Regional Administrator or Designee Date Signed A b C d e f 9 h I I k I ro n o P q f a t I e v I w I x Rate ISS Prof Svs Prof Svs Praf Svs Prof 5vs ISS Prot ISS Hold Total ISS Admin Admin Other Total Non- Total P1 Program Provider Effective Tier ISS Daily Hrs PCD Hrly Rate Hrs PCD Hrly Rate Svs Daily SS CRST Harmles Daily Admin Hold CRST Tlanap, Non -ISS ISS Oalty Dally Serrloe Name 101 ID ClisintName Client PllD Data Rate Tier Rate 1 1 2 2 Rate Tier Rate sRate Rate TiarRat -rierRate Rate Ftat93 Rate Ran Rwtslon caen)6> CUI fQll'- SA71 DrKr:rruNs WIDIMI 10007'lM2t'A 01 0(4019 _ S142.44 0.00 SO.Un n.00 Mull w(In V.6.1 .13,57 Y)5S.t4 5.13.36 1?.?i SU.66 'Li Al) U3,110 34);17 31t19.91 WI 1902IK) GRANT COI.M1' - SATI I- miti-crirm IVIDIMI I0019SI1,7WA 014112017 I VJ.N.13 O.OU };1),011 (MIn •>.OU 42).00 SIV 313.37 169.11 S19.95 52.25 40.25 54.00 WHO S?6.4i .96,16 3403 1IM2b raurrr CUUNIV . Onto S A716- A1RCV1l0t,N11rxU7 l IOU.125622WA 0101:?D)v 4 $29693 0.00 VIM 0.110 SO.nn %00 55.30 413.57 S305.90 336.44 52.35 S1.31 4-4(10 1i).OU 1:+4.02 b349.$2 360 19U2U0 ORAN7 SAiIG COUNTY nwic tio4S 2n1712S01 IUMSM93WA UTAII.24119 I 155,12 0.OU SO.W 0.1.10 400) 10.W 41.02 VI 337 $69.71 19.95 32.23 to.25 UAX SO.W .126.45 WO. 16 3M13 19(L(KI G"NI SAIJO- domp� 0U.,.,- nau;c-nf nx 20001?SOf I<IOLxSMBW,1 r>a07 *uly 3 1 3219.9 A) I MAX) (1.00 . U,tx) 1U.U0 I 14.00 1:1 3.57 1237.53 535.13 S2.25 I SIM Si (IO 30.(x) S43.40 f !`WO91 JhO1 1902(12 (:RAN) 1A 7) 6- VoONVY . olaarrulNs 20110175111 10U42Urt4ttrA U6'U1:m1Q 3 3119.9 (10) SU,IXI 0.(x) gU.W 30.00 TA. W, 113.57 51-37.53 .35.13 1`.35 51.02 t4MU 10.00 542.44) 4179.93 161B J90101) UR.V.I rix an' SA716• nlKl�'i'r 2U00l7501 IW1604 3\141 UI' n019 1 _ %55.12 U P WOO O.1x1 50.00 SO.UO %1.02 513.57 U9 71 31295 1??5 1021 UO 3OM 32h4i ',(96.16 1bU1 )91{00 URAW 5.471 t. CIER MY orarcnr>us 2mM 2501 I WiW3IOWA (W972019 3 K11129 0.001 110.00 1 0.00 t0JAI so. 4 1.06 113.57 S237,33 435.13 2 • S1Sn V 00 .00 442.40 .:79.93 MAY1 190202 GRAW 001:NIV - 1 2rx1U 1i01 IV07834D1\t'A U6:U7:?014 3 719 �) U.OII lXLIIU 0.00 UO Un 4x.06 313.?? 37.53 535.13 S2'S 02 $5.00 FU.UU 343,40 128U.93 3W3 190- s H Q) o Grant Integrated Services \ co 0 z Revision #: 190202 Page 1 of 2 C-1 (---D O d C- a D c d e I f 0 A i j k I ra a o p q r a 1 u v I w Rate ISS Prof Svs Prof Svs Prof Sva Prof Svs ISS Prof ISS Hold Total ISS Admin Admin Other Total tion- Total P1 Program Provider Effective Tier ISS Daily Hes PCD My Rate Hrs PCD Nrly Rate Svc Daily SS CRST Hatmles Daily Admin Had CRST Transp. Non453 ISS Dally Dally Service Name P1 10 ClitniNarn ClientP1 ID Date Rate Tier Rate 1 1 2 2 Rate Tfet Rate s Rate Rato Tier Rate -Tier Rate Rade Rates Rate Rats RAYif Ion GaAMI SA? I G- r.•txHt Y. UINF('7p.T+S ?Ulxll??(II (llli(O(17715 WA OIAI X1110 4 $286.93 (UX) V)Co MW .',111.00 30.00 S5.30 SI 7.57 S305.6O $30.1-3 X125 57.33 F4,0(1 '111.00 S44.02 .V.)49.82 .7601 190h1(I GXAH1 1 I Dlktr-mms 201xlI?,1411 WIMSem3WA 01 VI,1010 S S138,4 (J.(* YO.W 11.0D111.!X) Y(JAI $6.62 313.57 S378.63 $40.13 Q._'5 SIM b5.UU $U.W N44.01 712?h6 3603 19113110 tOCAt+I nntzsu»s ?uan?CJI �� t(IIr67? I :� lxinr�<nv 3 2,19,9 (l AO 3111•CY) U.lx) $U.(X) SUAJ 34.(M W.UO 3213,96 335.13 10.(10 31.112 W.U(I .11.00 .'1U.IS 11264 11 36113 1901.12 fi xAH1 t!� ti,17)( . �xn+lv,ti?a1w1?xn uulsrv�ta nr1 ^I 2 5143.44 U.W YU.M 4!X> $U.tR1 YU.(XI 53.63 313.57 Slix.(A 5.3336 6225 91.66 11-1.(10 SU. $40.27 1 1.)1 36113 190200 ('00111 don"03716 I ['1x11/1Y UIr•t3'110K.8_?pW l_;!AI IO2:1271.10il4'a U19)I!?(Iii, Y2fl'.9 0.1X1 I YO.U(1 I U.IX) 110.('.(1 I SU.UII 1 53.06 V11.5711 $35.13 1•2.2j I S1.IL 1 i:4 U[I $0.(X) 1 $42.40 V�79.43 3603 )9(12011 E^ rn o Grant Integrated Services Revision #: 990202 cfl 0 0 Page 2 of 2