HomeMy WebLinkAboutGrant Related - GRISSupported Living / Group Home -Exhibit C
K20-168
July 1, 2020 - June 30, 2021
Revision #: 210300
GRANT COUNTY - 01 200012501 1963-57191 1N 9/30/20 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. Thi
ratesheet revision supersedes all previous rate sheets as of the effective date.
nature Date Signed DSHS Regional Administrator or Designee Date Signed
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P
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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
Daily
Rate
#
GRANT
COUNTY-
SA716-
DIRECTIONS
I
100195167WA
10/01/2020
1
$62.56
0.00
$0.00
0.001
$0.00
$0.00 1
$1.16
$0.00
1 $63.72
$22.64
1 $10.76
$0.28
1 $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
$331.69
$41.36
$43.87
$1.51
$2.40
$4.54
$0.00
$93.68
$425.37
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
100388693WA
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
100388695WA
10/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4.61
$0.00
$254.20
$39.87
$34.88
$1.16
$2.40
$5.68
$0.00
$83.99
$338.19
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
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
10/01/2020
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
100598316WA
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
$34.75
$1.16
$2.40
$4.54
$0.00
$82.72
$336.92
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
100783401WA
10/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0.00
$4E02$00.000
$254.20
$39.87
$34.88
$1.16
$2.40
$5.68
$0.00
$83.99
$338.19
3603
210300
GRANT
COUNTY-
SA716-
DIRE TI NS
100807715WA
10/01/2020
4
$325.67
0.00
$0.00
0.00
$0.00
$0.00
$6
$331.69
$41.36
$43.87
$1.51
$2.40
$4.54
1 $0.00
$93.68
$425.37
3603
210300
GRANT COUNTY - 01
Revision #: 210300
Page 1 of 2
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a
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C
d
e
f
9
h
j
k
I
m
n
o
p
q
r
s
t
u
v
w
x
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
Daily
Rate
#
GRANT
COUNTY -
$A716-
DIRECTTONS
100859024WA
10/01/2020
1 5
$406.83
0.00
$0.00
0.00
$0.00
$0.00
$7.51
$0.00
$414.34.
$45.54
$54.031
$1.88
$2.40
$5.68
$0.00
1$109.53
523.87
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
100867261WA
10/01/2020
3
$249.59
0.00
$0.00
0.00
$0.00
$0,00
$4.61
0.00
$254.20
$39.87
$34.75
$1.16
$2.40
$4.54
$0.00
$82.72
$336.92
3603
210300
GRANT
COUNTY-
SA716-
DIRECTIONS
1ou58242WA
10/01/2020
2
$161.67
0.00
$0.00
0.00
$0.00
$0.00
$2.99
$0.00
$164.66
$37.86
$24.17
$0.75
$2.40
$4.54
$0.00
$69.72
$234.38
3603
210300
GRANT
COUNTY -
SA716-
DIRECTIONS
102327903WA
10/01/2020
3
$249.59
0.001
$0.00
0.001
$0.00
$0.00
$4.61
1 $0.00
1$254.20
1 $39.87
1 $34.75
1 $1.16
$2.40
1 $4.54
$0.00
1 $82.72
336.92
1 3603
210300
GRANT COUNTY - 01 Revision #: 210300 Page 2 of 2