Common use of ADDITIONAL GRANT INFORMATION Clause in Contracts

ADDITIONAL GRANT INFORMATION. Federal Award Identification Number (XXXX): B08TI083054-01 Federal Award Date: 10/01/2019 Name of Federal Awarding Agency: Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) CFDA Name and Number: 93.959 Awarding Official Contact Information: Xxxxxx Xxxxxxx, Grants Management Officer, Point of Contact is Xxxxx Xxxx, Grants Specialist, Contact Number: (000) 000-0000, Facsimile: (000) 000-0000, Email: Xxxxx.Xxxx@xxxxxx.xxx.xxx Xxxxx Xxxxxx Assoc. Commissioner IDD/BH Xxxxx Xxxxxxx Chief Executive Officer Date of execution: July 22, 2020 Date of execution: July 22, 2020 ATTACHMENT A: STATEMENT OF WORK TREATMENT FOR YOUTH A. Grantee shall provide Substance Use Disorder Treatment Services for one (1) or more of the following service types/levels of care. The below service types/levels of care are based on Texas Administrative Code (TAC) requirements, as referenced in the Substance Use Disorder (SUD) Utilization Management (UM) Guidelines, located at the following link: xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral-health-services- providers/substance-use-disorder-service-providers, and American Society of Addiction Medicine (ASAM) criteria located at the following link: xxx.xxxx.xxx, which is a collection of objective guidelines that give clinicians a standardized approach to admission and treatment planning. 1. Outpatient Treatment Services 2. Supportive Residential Treatment Services 3. Intensive Residential Treatment Services B. TREATMENT FOR YOUTH (TRY) Program Target Population

ADDITIONAL GRANT INFORMATION. Federal Award Identification Number (XXXX): B08TI083054-01 Federal Award Date: 10/01/2019 Name of Federal Awarding Agency: Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) CFDA Name and Number: 93.959 Awarding Official Contact Information: Xxxxxx Xxxxxxx, Grants Management Officer, Point of Contact is Xxxxx Xxxx, Grants Specialist, Contact Number: (000) 000-0000, Facsimile: (000) 000-0000, Email: Xxxxx.Xxxx@xxxxxx.xxx.xxx Name: Xxxxx Xxxxxx Name: Xxxx Xxxxxx Assoc. Commissioner IDD/BH Xxxxx Xxxxxxx Chief Executive Officer President & CEO Date of execution: July 22_August 13, 2020 Date of execution: July 22August 13, 2020 ATTACHMENT A: STATEMENT OF WORK TREATMENT FOR YOUTH A. Grantee shall provide Substance Use Disorder Treatment Services for one (1) or more of the following service types/levels of care. The below service types/levels of care are based on Texas Administrative Code (TAC) requirements, as referenced in the Substance Use Disorder (SUD) Utilization Management (UM) Guidelines, located at the following link: xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral-health-services- xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral- health-services-providers/substance-use-disorder-service-providers, and American Society of Addiction Medicine (ASAM) criteria located at the following link: xxx.xxxx.xxx, which is a collection of objective guidelines that give clinicians a standardized approach to admission and treatment planning. 1. Outpatient Treatment Services 2. Supportive Residential Treatment Services 3. Intensive Residential Treatment Services B. TREATMENT FOR YOUTH (TRY) Program Target Population

ADDITIONAL GRANT INFORMATION. Federal Award Identification Number (XXXX): B08TI083054-01 Federal Award Date: 10/01/2019 Name of Federal Awarding Agency: Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) CFDA Name and Number: 93.959 Awarding Official Contact Information: Xxxxxx Xxxxxxx, Grants Management Officer, Point of Contact is Xxxxx Xxxx, Grants Specialist, Contact Number: (000) 000-0000, Facsimile: (000) 000-0000, Email: Xxxxx.Xxxx@xxxxxx.xxx.xxx Xxxxx Xxxxxx Assoc. Commissioner IDD/BH Date of execution: _July 24, 2020 Xxxxxx Xxxxx Xxxxxxx Chief Executive Officer Date of execution: July 22, 2020 Date of execution: July 2223, 2020 ATTACHMENT A: STATEMENT OF WORK TREATMENT FOR YOUTH A. Grantee shall provide Substance Use Disorder Treatment Services for one (1) or more of the following service types/levels of care. The below service types/levels of care are based on Texas Administrative Code (TAC) requirements, as referenced in the Substance Use Disorder (SUD) Utilization Management (UM) Guidelines, located at the following link: xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral-health-services- xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral- health-services-providers/substance-use-disorder-service-providers, and American Society of Addiction Medicine (ASAM) criteria located at the following link: xxx.xxxx.xxx, which is a collection of objective guidelines that give clinicians a standardized approach to admission and treatment planning. 1. Outpatient Treatment Services 2. Supportive Residential Treatment Services 3. Intensive Residential Treatment Services B. TREATMENT FOR YOUTH (TRY) Program Target Population

ADDITIONAL GRANT INFORMATION. Federal Award Identification Number (XXXX): B08TI083054-01 Federal Award Date: 10/01/2019 Name of Federal Awarding Agency: Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) CFDA Name and Number: 93.959 Awarding Official Contact Information: Xxxxxx Xxxxxxx, Grants Management Officer, Point of Contact is Xxxxx Xxxx, Grants Specialist, Contact Number: (000) 000-0000, Facsimile: (000) 000-0000, Email: Xxxxx.Xxxx@xxxxxx.xxx.xxx Xxxxx Xxxxxx Name: Xxxxxxx Xxxxxx Assoc. Commissioner IDD/BH Xxxxx Xxxxxxx Chief Date of execution: _July 21, 2020 Title: Executive Officer Director/CEO Date of execution: July 22, 2020 Date of execution: July 2221, 2020 ATTACHMENT A: STATEMENT OF WORK TREATMENT FOR YOUTH A. ADULTS Grantee shall provide Substance Use Disorder Treatment Services for substance use disorder treatment services to the target population at one (1) or more of the following service types/levels of care. The below service types/levels of care are based on Texas Administrative Code (TAC) requirements, as referenced in the Substance Use Disorder (SUD) Utilization Management (UM) Guidelines, located at the following link: xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral-health-services- providers/substance-use-disorder-service-providers, and American Society of Addiction Medicine (ASAM) criteria located at the following link: xxx.xxxx.xxx, which is a collection of objective guidelines that give clinicians a standardized approach to admission and treatment planning. 1. Outpatient Treatment Services 2. Supportive Residential Treatment Services 3. Intensive Residential Treatment Services B. TREATMENT FOR YOUTH (TRY) Program Target Population

ADDITIONAL GRANT INFORMATION. Federal Award Identification Number (XXXX): B08TI083054-01 Federal Award Date: 10/01/2019 Name of Federal Awarding Agency: Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) CFDA Name and Number: 93.959 Awarding Official Contact Information: Xxxxxx Xxxxxxx, Grants Management Officer, Point of Contact is Xxxxx Xxxx, Grants Specialist, Contact Number: (000) 000-0000, Facsimile: (000) 000-0000, Email: Xxxxx.Xxxx@xxxxxx.xxx.xxx Xxxxx Xxxxxx Assoc. Commissioner IDD/BH Xxxxx Xxxxxxx Chief Executive Officer Name: Xxxxxxxx Xxxxxxxx Title: CEO Date of execution: July 2220, 2020 Date of execution: July 2220, 2020 ATTACHMENT A: STATEMENT OF WORK TREATMENT FOR YOUTH A. FEMALES Grantee shall provide Substance Use Disorder Treatment Services for one (1) or more of the following service types/levels of care. The below service types/levels of care are based on Texas Administrative Code (TAC) requirements, as referenced in the Substance Use Disorder (SUD) Utilization Management (UM) Guidelines, located at the following link: xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral-health-services- providers/substance-use-disorder-service-providers, and American Society of Addiction Medicine (ASAM) criteria located at the following link: xxx.xxxx.xxx, which is a collection of objective guidelines that give clinicians a standardized approach to admission and treatment planning. 1. Outpatient Treatment Services 2. Supportive Residential Treatment Services 3. Intensive Residential Treatment Services B. TREATMENT FOR YOUTH (TRY) Program Target Population

ADDITIONAL GRANT INFORMATION. Federal Award Identification Number (XXXX): B08TI083054-01 Federal Award Date: 10/01/2019 Name of Federal Awarding Agency: Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) CFDA Name and Number: 93.959 Awarding Official Contact Information: Xxxxxx Xxxxxxx, Grants Management Officer, Point of Contact is Xxxxx Xxxx, Grants Specialist, Contact Number: (000) 000-0000, Facsimile: (000) 000-0000, Email: Xxxxx.Xxxx@xxxxxx.xxx.xxx Name: Xxxxx Xxxxxx Name: Xxxxx Xxxxxxxx Assoc. Commissioner IDD/BH Xxxxx Xxxxxxx Chief Executive Officer CEO Date of execution: July 22August 20, 2020 Date of execution: July 22August 17, 2020 ATTACHMENT A: STATEMENT OF WORK TREATMENT FOR YOUTH A. ADULTS Grantee shall provide Substance Use Disorder Treatment Services for substance use disorder treatment services to the target population at one (1) or more of the following service types/levels of care. The below service types/levels of care are based on Texas Administrative Code (TAC) requirements, as referenced in the Substance Use Disorder (SUD) Utilization Management (UM) Guidelines, located at the following link: xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral-health-services- providers/substance-use-disorder-service-providers, and American Society of Addiction Medicine (ASAM) criteria located at the following link: xxx.xxxx.xxx, which is a collection of objective guidelines that give clinicians a standardized approach to admission and treatment planning. 1. Outpatient Treatment Services 2. Supportive Residential Treatment Services 3. Intensive Residential Treatment Services B. TREATMENT FOR YOUTH (TRY) Program Target Population

ADDITIONAL GRANT INFORMATION. Federal Award Identification Number (XXXX): B08TI083054-01 Federal Award Date: 10/01/2019 Name of Federal Awarding Agency: Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) CFDA Name and Number: 93.959 Awarding Official Contact Information: Xxxxxx Xxxxxxx, Grants Management Officer, Point of Contact is Xxxxx Xxxx, Grants Specialist, Contact Number: (000) 000-0000, Facsimile: (000) 000-0000, Email: Xxxxx.Xxxx@xxxxxx.xxx.xxx Xxxxx Xxxxxx Assoc. Commissioner IDD/BH Date of execution: _July 23, 2020 Xxxxx Xxxxxxx Chief Xxxxxxxx Executive Officer Director Date of execution: July 22, 2020 Date of execution: July 2220, 2020 ATTACHMENT A: STATEMENT OF WORK TREATMENT FOR YOUTH A. ADULTS Grantee shall provide Substance Use Disorder Treatment Services for substance use disorder treatment services to the target population at one (1) or more of the following service types/levels of care. The below service types/levels of care are based on Texas Administrative Code (TAC) requirements, as referenced in the Substance Use Disorder (SUD) Utilization Management (UM) Guidelines, located at the following link: xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral-health-services- providers/substance-use-disorder-service-providers, and American Society of Addiction Medicine (ASAM) criteria located at the following link: xxx.xxxx.xxx, which is a collection of objective guidelines that give clinicians a standardized approach to admission and treatment planning. 1. Outpatient Treatment Services 2. Supportive Residential Treatment Services 3. Intensive Residential Treatment Services B. TREATMENT FOR YOUTH (TRY) Program Target Population

ADDITIONAL GRANT INFORMATION. Federal Award Identification Number (XXXX): B08TI083054-01 Federal Award Date: 10/01/2019 Name of Federal Awarding Agency: Department of Health and Human Services (HHS), Substance Abuse and Mental Health Services Administration (SAMHSA) CFDA Name and Number: 93.959 Awarding Official Contact Information: Xxxxxx Xxxxxxx, Grants Management Officer, Point of Contact is Xxxxx Xxxx, Grants Specialist, Contact Number: (000) 000-0000, Facsimile: (000) 000-0000, Email: Xxxxx.Xxxx@xxxxxx.xxx.xxx Xxxxx Xxxxxx Assoc. Commissioner IDD/BH Xxxx Xxxxx Xxxxxxx Chief Executive Officer Date of execution: July 2220, 2020 Date of execution: July 2220, 2020 ATTACHMENT A: STATEMENT OF WORK TREATMENT FOR YOUTH A. Grantee shall provide Substance Use Disorder Treatment Services for one (1) or more of the following service types/levels of care. The below service types/levels of care are based on Texas Administrative Code (TAC) requirements, as referenced in the Substance Use Disorder (SUD) Utilization Management (UM) Guidelines, located at the following link: xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral-health-services- xxxxx://xxx.xxxxx.xxx/doing-business-hhs/provider-portals/behavioral- health-services-providers/substance-use-disorder-service-providers, and American Society of Addiction Medicine (ASAM) criteria located at the following link: xxx.xxxx.xxx, which is a collection of objective guidelines that give clinicians a standardized approach to admission and treatment planning. 1. Outpatient Treatment Services 2. Supportive Residential Treatment Services 3. Intensive Residential Treatment Services B. TREATMENT FOR YOUTH (TRY) Program Target Population