HomeMy WebLinkAboutGrant Related - BOCCSupported Living / Group Home -Exhibit C
July 1, 2019 - June 30, 2020 Revision #: 200300
Grant County 200012501 1963-57191 1N 4/13/20 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
rate sheet revision supersedes pll previous rate sheets as of the effective date.
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 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
Dailv
Rate
#
GRANT
SA716-
COUNTY-
DIREcrIONs I
100195167WA
04/01/2020 1
1
$62.56
0.00
$0.00
0.00
$0.00
$0.00 1
$1.16
$11.36
$75.08
$22.64
$25.82
$0.28
$2.36
$4.54
$0.00
$55.64
$130.72
3603
200300
GRANT
SA716-
COUNTY-
DIRECTIONS
100325622WA
04/01/2020
4
$325.67
0.00
$0.00
0.00
$0.00
$0.00
$6.02
$11.36
$343.05
$41.36
$89.17
$1.51
$2.36
$4.54
$0.00
$138.94
$481.99
3603
200300
GRANT
SA716-
couNTv-
DIRECTIONS
I
100388693WA
04/01/2020
1
$62.56
0.00
$0.00
0.00
$0.00
$0.00
$1.16
$11.36
$75.08
$22.64
$25.82
$0.28
$2.36
$4.54
$0.00
$55.64
$130.72
3603
200300
GRANT
SA716-
COUNTY-
DIRECTIONS
100388695wA
04/0//2020
3
$249.59
1 0.00
$0.00
0.00
$0.00
$0.00
$4.61
$11.36
1$265.56
$39.87
$71.96
$1.16
$2.36
$5.68
$0.00
$121.03
$386.59
1 3603
200300
GRANT
SA716-
COUNTY-
DIRECTIONS
100420644wA
04/0//2020
1 5
$406.83
0.00
$0.00
0.00
$0.00
$0.00
$7.51
$11.36
$425.70
$45.54
S108.35
$1.88
$2.36
1 $4.54
$0.00
$162.67
$588.37
3603
200300
GRANT
SA716-
COUNTY-
DIRECTIONS
100460 23W
04/01/2020
1
$62.56
0.00
$0.00
0.00
$0.00
$0.00
$1.16
$11.36
$75.08
$22.64
$25.82
$0.28
$2.36
$4.54
$0.00
$55.64
$130.72
3603
200300
GRANT
SA716-
COUNTY-
DIRECTIONS
100598316WA
04/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$11.36
$265.56
$39.87
$71.71
$1.16
$2.36
$4.54
$0.00
$119.64
$385.20
3603
200300
GRANT
SA716-
COUNTY-
DIRECTIONS
100783401WA
04/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$11.36
265.56
$39.87
$71.96
$1.16
$2.36
$5.68
$0.00
$121.03
$386.59
3603
200300
GRANT
$A716-
COUNTY -
DIRECTIONS
100807715WA
04/01/2020
4
$325.67
0.00
$0.00
0.00
$0.00
$0.00
$6.02
$11.36
$343.05
$41.36
$89.17
$1.51
1 $2.36
$4.54
$0.00
$138.94
$481.99
3603
200300
Grant County Revision #: 200300 Page 1 of 2
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Program
Name
Client Name
Client P1 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
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
#
GRANT
COUNTY-
SA716-
DIRECTIONS
100859024WA
04/01/2020
1 5
S406.831
0.00
$0.001
0.00
x';0.00
50.00
57.51
$11.36
$425.70.
$45.54
S108.601
$1.88
$2.36
$5.68
$0.00
$164.06
589.76
3603
200300
GRANT
COUNTY-
SA716-
DIRECTIONS
100867261WA
04/01/2020
3
$249.59
0.00
$0.00
0.00
50.00
50.00
$4.61
$11.36
$265.56
$39.87
$71.71
$1.16
$2.36
$4.54
$0.00
$119.64
$385.20
3603
200300
GRANT
COUNTY-
SA716-
DIRECTIONS
101158242WA
04/01/2020
2
$161.67
0.001
$0.00
0.00
$0.00
$0.00
$2.99
$11.36
$176.02
$37.86
$51.48
$0.75
$2.36
$4.54
$0.00
$96.99
$273.01
1 3603
200300
GRANT
couNrY -
SA716-
DIRECTIONS
102327903wA
04/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$11.36
$265.56
$39.87
$71.71
$1.16
$2.36
$4.54
$0.00
$119.64
$385.20
3603
200300
Grant County Revision #: 200300 Page 2 of 2