Attachment E. Data Use Agreement-TACCHO Version Attachment F – Federal Assurances-v1.1 Attachment G – Certification Regarding Lobbying Attachment H – FFATA Certification Form
Attachment E. EQUITY-BASED REQUIREMENT – Description of the project’s equitable design and implementation by addressing the program’s equity goals, awareness, access and distribution, and outcomes.
Attachment E. Special Conditions version 1.2, is hereby revised and restated in its entirety with Attachment E – Special Conditions, version 1.3 (Revised May 2021).
Attachment E. Sample Purchase Order
Attachment E. The United States Department of Transportation Standard Title VI/Non-Discrimination Assurances DOT Order No. 1050.2A
Attachment E. SPECIAL CONDITIONS, version 1.2, is hereby deleted and replaced in its entirety with ATTACHMENT E – SPECIAL CONDITIONS, version 1.3 (REVISED SEPTEMBER 2021).
Attachment E.
3.4.1 E: VDSA Non-MSP Response File Layout – 500 bytes
1. Filler 4 1-4 BCRC use.
2. SSN 9 5-13 Beneficiary’s SSN. Included for Action Types D, S, and N. Field will contain either the SSN that matched, or a corrected SSN based on a Medicare ID match.
3. Medicare ID 12 14-25 Medicare ID (Health Insurance Claim Number [HICN] or Medicare Beneficiary Identifier [MBI]). Included for Action Types D, S, and N. If the information submitted on the input record was matched to a Medicare beneficiary, this field will contain the most current Medicare ID for the beneficiary.
4. Covered Individual’s Surname 6 26-31 Beneficiary’s Last Name. Included for Action Types D, S, and N. Field will contain either the name supplied or corrected name from BCRC database.
5. Beneficiary First Initial 1 32 Beneficiary’s First Initial. Included for Action Types D, S, and N. Field will contain either the value supplied or corrected value from BCRC database.
6. Beneficiary Middle Initial 1 33 Beneficiary’s Middle Initial. Included for Action Types D, S, and N. Field will contain the value supplied.
7. Beneficiary Date of Birth 8 34-41 Beneficiary’s DOB (CCYYMMDD). Included for Action Types D, S, and N. Field will contain either the value supplied or a corrected value from BCRC database.
8. Beneficiary Sex Code 1 42 Beneficiary’s Sex: 0 = Unknown 1 = Male 2 = Female Included for Action Types D, S, and N Field will contain either the value supplied or a corrected value from BCRC database.
9. Group Health Plan Number 20 43-62 GHP Number assigned by Payer for Action Type D, or, Unique Benefit Option Identifier, as defined by the RDS Center, and assigned by Payer for Action Types S. Included for Action Types D and S. Field will contain the value supplied on input.
10. Individual Policy number 17 63-79 Policy Number. Included for Action Types D and S. Field will contain the value supplied on input.
11. Effective Date 8 80-87 Start Date of Beneficiary’s Insurance Coverage. (CCYYMMDD). Included for Action Types D and S. Field will contain the effective date applied to the CWF and/or Drug record.
12. Termination Date 8 88-95 End Date of Beneficiary’s Insurance Coverage. (CCYYMMDD) All zeros if open-ended or non-applicable. Included for Action Types D and S. Field will contain the term date applied to the CWF and/or Drug record.
13. Filler 10 96-105 Unused field. Space filled.
14. Rx Insured ID number 00 000-000 Insured’s Identification Number. Included for Action Types D and S. Field will conta...
Attachment E. Data Use Agreement;
Attachment E to Master Price Agreement by and between VENDOR and PURCHASER.
Attachment E. BUSINESS ASSOCIATE AGREEMENT
