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HomeMy WebLinkAboutGrant Related - BOCC (004)Zo-ia3 15 Supported Living / Group Home -Exhibit C July 1, 2020 - June 30, 2021 Revision #: 210100 Grant County 200012501 1963-57191 1N 6/30/20 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 rete sheet revision supersedes all previous rate sheets as of the effective date. 8/12/20 Contractor Signature Date S fined DSHS Regional Administrator or Designee Date Signed =COUNTYSSIOIZRS Grant County Revision #: 210100 Page 1 of 2 o a r n I x I q t R.I. Prof Sva Profs- Is5 Prof ISS Hold Total ISS Abnin Admin Other Total Told P1 Proanm Nene CibM Name Cllent Pt ID Effective Date ISS Tier Rate ISS Daly Tier Rate Prof Sva Hr. PCD 1 MyRab 1 laro/Sve PCD 2 My Rata 2 S.. Daily Rate ISS CRST Tier Rate Harmba a Rate Daly Rate Admin ier Rate Had CRST Tier Rd. Cert Rab snap. Rab Non- ISS NoMSS Dai Daily Rab 9avb Rerblon GMN coUN oNs I I95167wA o 1 6 0.00 .00 0.00 $0.00 .00 I.Ib $0.00 3.72 22.64 .00 .28 .40 .54 .00 .86 3.58 SA7I6 3603 10100 SA716 ulxe. ao Iz 22wA o7/olrzozo 4 $325.67 OM $0.00 0. $0,00 $0.00 .02 $0.00 $331.69 %41.36 $0.00 $1.51 $2.40 $4.54 $0.00 S49.81 $391.50 3603 210100 caAH SA716- aotrt _ Dlat�nralti, IN39803WA 7MI12020 1 $62.56 0.90 .00 0.00 .00 $1.16. .00 3.72 $22.64 .00 .28 52.40 .54 .00 29.86 3.58 3603 210100. oMHr SA716 i8ern IN3980SWA OMIM20 3 5249.59 0.00 $0.00 0.00 $0.001 90.00 S4.61 SO.00 S254.20 S39.87 $0.00 $1.16 $2.40 $5.68 $0.00 $49.11 $30331 3603 210100 OMNT 5 MUNW- 131-SI00420644WA 07/01/2020 5 $406.83 0. .00 O.OD .00 .00 .51 .00 1434 5.54 .00 1.88 .40 54.54 E0.00 54.36 68.70 3603 3603 10100 cMN SA716 cal s 10D/60423WA 01/OInWO 1 562.56 0.00 moo 0.00 $0.00 $0.00 $1.16 $0.00 $63.72 1 S22.64 $0.00 90.281 $2.40 S4.54 50.00 I 529.86 $93.58 3603 210100 GMH 5 couN7y- I 598 16WA a7rol 0 3 E249.59 0.00 .00 0.00 $0.00 .00 54.61 .OD $25420 539.87 50.00 1.16 .40 54.54 .00 7.97 5302.17 3603 3603 10100 GMM 716 clxmry I IWA 97ro1rz(120 3 $249.59 0. .00 .00 0.00 .61 .00 5420 9.87 .f10 1.1 .40 5.68 50.0(1 $49.11 30 1 60 101 OMM SA716 coUNry- I WA roIR020 4 5325 0.00 50.00 0.00 $0.00 $0.00 .02 .00 331.69 136 .00 1.51 2.40 .00$49.81 381.50 603 107 =COUNTYSSIOIZRS Grant County Revision #: 210100 Page 1 of 2