Common use of PROVIDER COVERED SERVICES Clause in Contracts

PROVIDER COVERED SERVICES. I confirm that the PROVIDER/ENTITY named herein will be providing the service(s) listed below for enrollees of provider network for Medicaid, Medicare, and other programs (“PLAN”) (as applicable) on behalf of the Plan. (Check applicable services below) ☐ Adult Companion Services ☐ Adult Day Health Services ☐ Assisted Living Facilities ☐ Assistive Care Services ☐ Attendant Services ☐ Behavior Management ☐ Caregiver/Family/Skill Training ☐ Case Management ☐ Chore Services ☐ Consumable Medical Supplies ☐ Dental Services ☐ Home/Environmental Accessibility Adaptation ☐ Escort Services ☐ Financial Assessment/Risk Management ☐ Hearing Services ☐ Home Delivered Meals ☐ Homemaker Services ☐ Hospice ☐ Intermittent & Skilled Nursing ☐ Medical Equipment ☐ Medication Administration ☐ Medication Management ☐ Nursing Facility Care ☐ Nutrition/Risk Reduction ☐ Occupational Therapy ☐ Personal Care Services ☐ PERS (Emergency Response System) ☐ Physical Therapy ☐ Respite Care Services ☐ Respiratory Therapy ☐ Speech Therapy ☐ Vision Services ☐ Transportation ☐ Other: Signature X Date: All providers, who are mandated reporters of abuse, neglect, and exploitation, must attest that their staff has received the appropriate training. Please complete this Attestation by marking next to the applicable statement. Additionally, all providers and their employees with direct contact with enrollees must have completed Abuse, Neglect, and Exploitation Training. Please complete this Attestation as evidence of your compliance by marking next to the applicable statement. Provider Name/City/State: Signature: X Print Name & Title: Email: Date: I hereby attest that my organization has read and understands the CMS Compliance and Fraud, Waste, and Abuse (FWA) Training and agrees to abide by the laws and regulations therein upon the initial term of my contractual status and annually thereafter. I have read and agree to comply with all of the ILS written compliance policies and procedures and Standards of Conduct, and will implement and distribute them to all employees and board members of my organization. I, nor any employees of my organization, have not been convicted of, or charged with, a criminal offense related to health care, nor have I been listed by a federal agency as debarred, excluded or otherwise ineligible for participation in federally funded health care programs. I agree to review the HHS OIG List of Excluded Individuals & Entities list at xxxx://xxx.xxx.xxx/exclusions/exclusions_list.asp and GSA Debarment list monthly for all employees and downstream entities of my organization. I agree to immediately disclose any exclusion, or other event that makes my organization ineligible to perform work related directly or indirectly to Federal health care programs, to Independent Living Systems, LLC. I have effectively screened my organization’s governing bodies and senior leadership for conflicts of interest. I agree to report suspected violations of any laws and regulations to Independent Living Systems, LLC. I understand that any violation of any laws and regulations is grounds for disciplinary action, up to and including termination of my contractual status. I am aware that I am protected from retaliation for False Claims Act complaints, as well as any other applicable anti-retaliation protections. Unless otherwise noted in the space immediately below, I am not aware of any possible violations of any laws and regulations at this time. Provider Name/City/State: Signature: X Print Name & Title: Email: Date: (Page 1 of 2) CMS technical guidance and State requirements, recognizes the importance of ensuring that enrollees who reside in Residential Facilities reside in Home-Like Environments (HLE) and experience community inclusion to the fullest extent possible. There is specific provider contract language on this subject. To access Medicaid Home and Community Based funding all Residential Facility Provider must maintain a home-like environment and community integration. Indicate the HLE characteristics and the Community Integration Goal Planning below. Use the space provided to comment on any “NO” responses.

PROVIDER COVERED SERVICES. I confirm that the PROVIDER/ENTITY named herein will be providing the service(s) listed below for enrollees of provider network for Medicaid, Medicare, and other programs (“PLAN”) (as applicable) on behalf of the Plan. (Check applicable services below) ☐ Adult Companion Services ☐ Adult Day Health Services ☐ Assisted Living Facilities ☐ Assistive Care Services ☐ Attendant Services ☐ Behavior Management ☐ Caregiver/Family/Skill Training ☐ Case Management ☐ Chore Services ☐ Consumable Medical Supplies ☐ Dental Services ☐ Home/Environmental Accessibility Adaptation ☐ Escort Services ☐ Financial Assessment/Risk Management ☐ Hearing Services ☐ Home Delivered Meals ☐ Homemaker Services ☐ Hospice ☐ Intermittent & Skilled Nursing ☐ Medical Equipment ☐ Medication Administration ☐ Medication Management ☐ Nursing Facility Care ☐ Nutrition/Risk Reduction ☐ Occupational Therapy ☐ Personal Care Services ☐ PERS (Emergency Response System) ☐ Physical Therapy ☐ Respite Care Services ☐ Respiratory Therapy ☐ Speech Therapy ☐ Vision Services ☐ Transportation ☐ Other: Signature X Date: Date All providers, who are mandated reporters of abuse, neglect, and exploitation, must attest that their staff has received the appropriate training. Please complete this Attestation by marking next to the applicable statement. Additionally, all providers and their employees with direct contact with enrollees must have completed Abuse, Neglect, and Exploitation Training. Please complete this Attestation as evidence of your compliance by marking next to the applicable statement. Provider Name/City/State: Signature: X Print Name & Title: Email: Date: I hereby attest that my organization has read and understands the CMS Compliance and Fraud, Waste, and Abuse (FWA) Training and agrees to abide by the laws and regulations therein upon the initial term of my contractual status and annually thereafter. I have read and agree to comply with all of the ILS written compliance policies and procedures and Standards of Conduct, and will implement and distribute them to all employees and board members of my organization. I, nor any employees of my organization, have not been convicted of, or charged with, a criminal offense related to health care, nor have I been listed by a federal agency as debarred, excluded or otherwise ineligible for participation in federally funded health care programs. I agree to review the HHS OIG List of Excluded Individuals & Entities list at xxxx://xxx.xxx.xxx/exclusions/exclusions_list.asp and GSA Debarment list monthly for all employees and downstream entities of my organization. I agree to immediately disclose any exclusion, or other event that makes my organization ineligible to perform work related directly or indirectly to Federal health care programs, to Independent Living Systems, LLC. I have effectively screened my organization’s governing bodies and senior leadership for conflicts of interest. I agree to report suspected violations of any laws and regulations to Independent Living Systems, LLC. I understand that any violation of any laws and regulations is grounds for disciplinary action, up to and including termination of my contractual status. I am aware that I am protected from retaliation for False Claims Act complaints, as well as any other applicable anti-retaliation protections. Unless otherwise noted in the space immediately below, I am not aware of any possible violations of any laws and regulations at this time. Provider Name/City/State: Signature: X Print Name & Title: Email: Date: (Page 1 of 2) CMS technical guidance and State requirements, recognizes the importance of ensuring that enrollees who reside in Residential Facilities reside in Home-Like Environments (HLE) and experience community inclusion to the fullest extent possible. There is specific provider contract language on this subject. To access Medicaid Home and Community Based funding all Residential Facility Provider must maintain a home-like environment and community integration. Indicate the HLE characteristics and the Community Integration Goal Planning below. Use the space provided to comment on any “NO” responses.