Common use of TERMINATION OF AGREEMENT AND APPEALS Clause in Contracts

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only for payment in accordance with the payment provision of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect as soon as the agreement is signed by both parties to the agreement. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Administrator Grants & Contracts Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider Consultant agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider Consultant eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider Consultant may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider Consultant may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Consultants, as soon as the agreement is signed directed by both parties to the agreementXXXX. This Agreement remains in force until the Provider Consultant or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider Consultant agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER CONSULTANT DEPT. OF HEALTH & SOCIAL SERVICES _ Signature of Authorized Provider Consultant Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants Grants, Contracts & Contracts Chief_ Facilities Chief Printed Name Provider Consultant Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxx Xxxxxxx, Health Program Manager Alaska Psychiatric Institute II Division of Behavioral Health 0000 Xxxxx Xxxxxx X Xx Xxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Administrator Grants & Contracts Provider Email Address PO Box 110650 Juneau, AK 9981199503-0650 5935 Ph. 000-000-0000 Fax 000- 000-000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxEmail: xxxx.xxxxxxx@xxxxxx.xxx DSM: xxxx.xxxxxxx@xxx.xxx.xxxxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ days written notice. A Provider may also terminate the Agreement with 30 days’ days written notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. By my signature below, I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact Name & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxX. Xxxxx, Program Manager Alaska Psychiatric Institute Division of Public Assistance 0000 X Xxxxxx Xxxxx Xxxxxx Anchorage000, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Xxxxxxxxx XX 00000 Xxxxxxxx.Xxxxx@Xxxxxx.xxx Ph. 000-000-0000 Fax 000-000-0000 Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxPlace, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxXxxxxx.Xxxxx@Xxxxxx.xxx Providers must identify the business entity type under which they are legally eligible to provide services and are intending to enter into this Provider Agreement.

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS DOH immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSSDOH. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS DOH may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only notice but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementXXX. This Agreement remains in force until the Provider or DHSS DOH terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement Agreement on behalf of the Provider agency named in this agreementAgreement, and hereby consent to the terms and conditions of this agreementAgreement, and its appendices and attachments. PROVIDER DEPT. DEPARTMENT OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS DOH Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants & Grants, Contracts Chief_ and Facilities Chief Printed Name Provider Representative & Title Printed Name - DHSS DOH Representative & Title Provider Contact & Mailing Address DHSS DOH Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxx Xxxxx, Program Manager Alaska Psychiatric Institute Division of Behavioral Health 0000 X Xxxxxx, Xxxxx Xxxxxx Anchorage000 Xxxxxxxxx, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx XX 00000 Ph. 000-000-0000 Ema il: xxxx.xxxxx@xxxxxx.xxx Direct Secure Message Email: xxx.xxx.xxxxxxxxxx@xxx.xxx.xxxxx xxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxx XxXxxxx, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000 000-0000 Fax 000- 000 000-0000 Provider’s Federal Tax ID IRIS Vendor Number xxxxxx.xxxxx@xxxxxx.xxxEma il: xxxxx.xxxxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. The Parties will collaborate in good faith to attempt to remedy any issues that might result in the termination of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only notice but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name of Provider Representative & Title Printed Name - of DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Program Contact Xxxxxx Xxxxxx, Tribal Title IV-E Program Manager Coordinator Office of Children’s Services P.O. Box 110630 Juneau, Alaska Psychiatric Institute 00000-0000 Xxxxx Phone: 000-000-0000 Fax: 000-000-0000 xxxxxx.xxxxxx@xxxxxx.xxx Administrative Contact Xxxxxx AnchorageXxxxxx-Xxxxxxxx, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Grants Administrator Grants & Contracts Provider Email Address PO P.O. Box 110650 Juneau, AK 9981100000-0650 Ph. 0000 Phone: 000-000-0000 Fax 000- Fax: 000-000-0000 Xxxxxx.xxxxxx-xxxxxxxx@xxxxxx.xxx Signed provider agreements and documents demonstrating provider eligibility must be emailed to: XXX.XXX.Xxxxxx.Xxxxxxxx.Xxxxxxxxxx@xxxxxx.xxx. Provider Phone Number / Fax Number Provider Email Address Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxProvider’s IRIS Vendor Number

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. The Parties will collaborate in good faith to attempt to remedy any issues that might result in the termination of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only notice but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name of Provider Representative & Title Printed Name - of DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Program Contact Xxxxxx Xxxxxx, Tribal Title IV-E Program Manager Coordinator Office of Children’s Services P.O. Box 110630 Juneau, Alaska Psychiatric Institute 00000-0000 Xxxxx Phone: 000-000-0000 Fax: 000-000-0000 xxxxxx.xxxxxx@xxxxxx.xxx Administrative Contact Xxxxxx AnchorageXxxxxx-Xxxxxxxx, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Grants Administrator Grants & Contracts Provider Email Address PO P.O. Box 110650 Juneau, AK 9981100000-0650 Ph. 0000 Phone: 000-000-0000 Fax 000- Fax: 000-000-0000 Xxxxxx.xxxxxx-xxxxxxxx@xxxxxx.xxx Signed provider agreements and documents demonstrating provider eligibility must be emailed to: XXX.XXX.Xxxxxx.Xxxxxxxx.Xxxxxxxxxx@xxxxxx.xxx. Provider Phone Number / Fax Number Provider Email Address Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx(EIN only, do not list SSN) Provider’s IRIS Vendor Number

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement Agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreementAgreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name Authorized Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxx Xxxxxx, Program Manager Alaska Psychiatric Institute Coordinator Division of Behavioral Health 0000 X Xxxxxx, Xxxxx Xxxxxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Alaska 00000-0000 Phone (000) 000-0000 xxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxxxxx Xxxxxx, Xxxxxx Grants Administrator Grants & Contracts Provider Email Address Support Team PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000Provider Email Address Phone (000)000-0000 Fax 000- 000-0000 Provider’s xxxxxxxx.xxxxxx@xxxxxx.xxx Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxFederal Tax ID Number

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement Agreement on behalf of the Provider agency named in this agreementAgreement, and hereby consent to the terms and conditions of this agreementAgreement, and its appendices Appendices and attachmentsAttachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS DHSSDOH Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address Provider Phone Number/ Fax Number _ Provider Email Address _ Provider’s Federal Tax ID Number - Do Not List SSN Xxx Xxxxx - Grants & Procurement Chief DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxxxxxxxx Xxxxx, Health Program Manager Alaska Psychiatric Institute II Senior and Disabilities Services, General Relief 0000 Xxxxx Xxxxxx Xx. Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number Ph. 000-000-0000 / xxxxxxxxxx.xxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxx Xxxxxxx, Xxxxxx Xxxxx Administrator III Grants & Contracts Provider Email Address Support Team, SDS PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx000-000-0000/xxxx.xxxxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS DFCS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- eligibility ineligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSSDFCS. A Provider may appeal the a decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals Appeals will be conducted in accordance with Section 7AAC 7 AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS DFCS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only notice and must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers as soon as the agreement is signed directed by both parties to the agreementDFCS. This Agreement remains in force until the Provider or DHSS DFCS terminates the Agreement Agreement, or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute execute, and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, its appendices, and its appendices and attachments. PROVIDER DEPT. DEPT OF HEALTH FAMILY & SOCIAL COMMUNITY SERVICES Signature of Authorized Provider Representative & Date Data Signature of DHSS DFCS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name & Title of Provider Representative Printed Name & Title Printed Name - DHSS of DFCS Representative & Title Provider Contact DFCS Contacts & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx UNIT Xxxxxx X Xxxxxx-Xxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Coordinator 2 Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Administrator Grants & Contracts Provider Email Mailing Address Division of Juvenile Justice PO Box 110650 Juneau, AK 9981100000-0650 Ph. 0000 Phone: (000) 000-0000/Fax: (000) 000-0000 Provider Phone Number/Fax 000- 000Number Xxxxxx.Xxxxxx-Xxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Xxxxxxxxxx Xxxxxxx, Grants Administrator Provider Email Address Grants & Contracts Support Team PO Box 112650 Juneau, AK 99811-0000 2650 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxPhone: (000) 000-0000 xxxxxxxxxx.xxxxxxx@xxxxxx.xxx Providers must identify the business entity type under which they are legally eligible to provide service and intending to enter into this Provider Agreement. Confirm entity type below. Non-Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) SUBMITTAL CHECKLIST Scan the following documents as a single file. The Provider Agreement section is 4.06, Question 1. The following documents, each completed and signed by an authorized agency signer: Provider Agreement, first and last pages or the entire document; Provider Agreement Appendix C, Federal Assurances and Certifications; Provider Agreement Appendix D, Federal EEOP Certifications; and Request for Waiver of Staff Requirement(s) if requesting. The uploaded file must also include:

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS DOH immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSSDOH. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS DOH may terminate this Agreement with 30 days’ notice. A Provider Consultant may also terminate the Agreement with 30 days’ notice. The State is liable only notice but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDOH. This Agreement remains in force until the Provider or DHSS DOH terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute execute, and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES _ Signature of Authorized Provider Representative & Date Signature of DHSS DOH Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants & Grants, Contracts Chief_ and Facilities Chief Printed Name Provider Representative & Title Printed Name - DHSS DOH Representative & Title Provider Contact & Mailing Address DHSS DOH Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxx Xxxxxxx, Health Program Manager Alaska Psychiatric Institute II Division of Behavioral Health 0000 Xxxxx Xxxxxx X Xx Xxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99503-5935 Ph. 000-000-0000 Fax 000-000-0000 Email: xxxx.xxxxxxx@xxxxxx.xxx DSM: xxxx.xxxxxxx@xxx.xxx.xxxxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-000-0000 Provider’s Federal Tax ID Number Email: xxxxxx.xxxxx@xxxxxx.xxx. Provider’s IRIS Vendor Number

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement Agreement on behalf of the Provider agency named in this agreementAgreement, and hereby consent to the terms and conditions of this agreementAgreement, and its appendices Appendices and attachmentsAttachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name Provider Representative & Title Printed Name Xxx Xxxxx - DHSS Representative Grants & Title Procurement Chief Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxxxx Xxxxx, Health Program Manager Alaska Psychiatric Institute 0000 Xxxxx II Senior and Disabilities Services, General Relief 000 Xxxx 0xx Xxxxxx Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99501 Ph. 000-000-0000 / Xxxxxx.Xxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxx Xxxxxx, Xxxxxx Xxxxx Administrator III _ Grants & Contracts Support Team, SDS Provider Email Address PO Box 110650 Juneau, AK 99811-0650 _ Ph. 000-000-0000 Fax 000- 000-0000 / Xxxxx.Xxxxxx@xxxxxx.xxx Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxNumber

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ days notice. A Provider may also terminate the Agreement with 30 days’ days notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx& Date Xxxxx Xxxxxx, Chief, Grants & Contracts Chief_ Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxCONTACTS Xxxxxxx Xxxxx, Program Manager Alaska Psychiatric Institute Youth ISA Xxxxxxx.Xxxxx@xxxxxx.xxx (000) 000-0000 Xxxxx (000) 000-0000 (Fax) Direct Secure Message: akdhss.dbh xxxxxx@xxxxxx.xxxxxxxxx.xxx Xxx XxXxxxxxxx, Adult ISA Xxxxx.xxxxxxxxxx@xxxxxx.xxx (000) 000-0000 (000) 000-0000 (fax) Direct Secure Message: akdhss.dbh xxxxxxxxxxx@xxxxxx.xxxxxxxxx.xxx Division of Behavioral Health 0000 X Xxxxxx Xxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 00000-0000 Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxx XxXxxxx, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxxxxxx.xxxxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ days notice. A Provider may also terminate the Agreement with 30 days’ days notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. PROVIDER CERTIFICATION: I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxxxx Xxxxxx, Grants & Contracts Chief_ G&CST Chief Officer Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxxx Xxxxxxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx AnchorageHeating Assistance Coordinator Division of Public Assistance 000 Xxxxxxxxxx, Suite 301 Juneau, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99801 Ph: 000-000-0000; Fax: 000-000-0000 Xxxxx.Xxxxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxxxx Xxxxx, Xxxxxx Xxxxx Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 0000; Fax 000- 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxXxxxxxx.Xxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS the department immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSSDOH. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS DOH may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only notice but must provide assistance in making arrangements for payment in accordance with safe and orderly transfer of clients and information to other Providers, as directed by the payment provision of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect as soon as the agreement is signed by both parties to the agreementdepartment. This Agreement remains in force until the Provider or DHSS DOH terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute execute, and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, agreement and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES PROVIDER: Alaska Department of Health Signature of Authorized Provider Representative & Date Signature of DHSS DOH Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants Grants, Contracts & Contracts Chief_ Facilities Chief Printed Name Provider Representative & Title Printed Name - DHSS DOH Representative & Title Provider Contact & Mailing Address DHSS DOH Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx AnchorageXxxx Xxxxxxx-Xxxx Division of Behavioral Health PO Box 110620 Juneau, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99811-0620 __________________________________________ 000-000-0000 Provider UEI Number xxxx.xxxxxxx-xxxx@a la ska .gov _______________________________________ Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxx XxXxxxx, Xxxxxx Grants Administrator ____________________________________ Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 ____________________________________ Ph. 000-000- 000-0000 Fax 000- 000-0000 Provider’s Federal Tax ID IRIS Vendor Number xxxxxx.xxxxx@xxxxxx.xxxxxxxx.xxxxxxx@xxxxxx.xxx Providers must identify the business entity type under which they are legally eligible to provide service and intending to enter into this Provider Agreement. Check Entity Type: Private For-profit Business, licensed to do business in the State of Alaska Non-Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA)

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS DOH immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSSDOH. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS DOH may terminate this Agreement with 30 days’ notice. A Provider Consultant may also terminate the Agreement with 30 days’ notice. The State is liable only notice but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDOH. This Agreement remains in force until the Provider or DHSS DOH terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. DEPTARTMENT OF HEALTH & SOCIAL SERVICES _ Signature of Authorized Provider Representative & Date Signature of DHSS DOH Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants & Grants, Contracts Chief_ and Facilities Chief Printed Name Provider Representative & Title Printed Name - DHSS DOH Representative & Title Provider Contact & Mailing Address DHSS DOH Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxx Xxxxxxx, Health Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx AnchorageII Division of Behavioral Health 3601 X Xx Xxx 000 Xxchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99503-5935 Ph. 000-000-0000 Fax 000-000-0000 Email: xxxx.xxxxxxx@xxxxxx.xxx DSM: xxxx.xxxxxxx@xxx.xxx.xxxxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-000-0000 Provider’s Federal Tax ID Number Email: xxxxxx.xxxxx@xxxxxx.xxx. Provider’s IRIS Vendor Number

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS DFCS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSSDFCS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS DFCS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDFCS. This Agreement remains in force until the Provider or DHSS DFCS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH FAMILY & SOCIAL COMMUNITY SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Provider Phone Number/ Fax Number Provider Email Address Provider’s Federal Tax ID Number Signature of DFCS Representative & Date Xxxxxxx Xxxxx, Division Operations Manager Printed Name - DFCS Representative & Title DFCS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxxxx, Program Manager Xxxxx Xxxxxxx Chief Financial Officer Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Administrator Grants & Contracts Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. xxxxx.xxxxxxx@xxxxxx.xxx Phone: (000-) 000-0000 Fax 000- Fax: (000) 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxDSM: see subsection VI., above ADMINISTRATIVE CONTACT

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ days notice. A Provider may also terminate the Agreement with 30 days’ days notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providers, as directed by DHSS. The State is liable only for payment in accordance with notice must include the payment provision of this date on which the Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect as soon as the agreement is signed by both parties will cease to the agreementprovide Ladies First Consultant/Resource services. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxx X. Xxxxx, Grants & Contracts Chief_ Manager, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxx X. Xxxxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx Director Division of Public Health PO Box 240249 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99524 Phone: (000) 000-0000 / Fax: (000) 000-0000 Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxx Xxxxxxx, Xxxxxx Administrator Grants & Contracts Provider Email Address Support Team PO Box 110650 Provider Contact Email Address Juneau, AK 9981100000-0650 Ph. 0000 Phone: (000-) 000-0000 Fax 000- / Fax: (000) 000-0000 Email: Xxxx.Xxxxxxx@xxxxxx.xxx Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx(EIN only, no SSN) --AGREEMENT EFFECTIVE UPON COMPLETION OF BOTH PARTIES SIGNATURES--

TERMINATION OF AGREEMENT AND APPEALS. This agreement is effective until June 30, 2012. Services authorized under this Consultant agreement must be completed by June 30, 2012. Possible yearly extensions of the Provider Agreement will be based on funding availability. The Provider Consultant agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements qualifications set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider Consultant may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ days notice. A Provider Consultant may also terminate the Agreement with 30 days’ days notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other service providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider Consultant or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER CONSULTANT DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Consultant Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name Provider Consultant Representative & Title Printed Name - DHSS Representative & Title Provider Consultant Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxx Xxxxxxxx, Program Manager Alaska Psychiatric Institute Mental Health Clinician III Division of Behavioral Health 0000 X Xx., Xxxxx Xxxxxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider 99503 Phone(907) 000-0000 / Fax (000) 000-0000 Consultant Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx Xxxxx, Xxxxxx Grants Administrator Grants & Contracts Provider Email Address Support Team PO Box 110650 Consultant’s Federal Tax ID Number Juneau, AK 99811-0650 Ph. (000-) 000-0000 / Fax 000- (000) 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx0000

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants Grants, Contracts & Contracts Chief_ Facilities Chief Printed Name of Authorized Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxxxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx AnchorageMental Health Clinician III Division of Behavioral Health PO Box 110620 Juneau, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider 00000-0000 Phone Number/ 000 000-0000 Fax 000 000-0000 xxxxxxxx.xxxxxxx@xxxxxx.xxx Provider’s Federal Tax ID Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxxxxx Xxxxxx, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address Phone Number / Fax PO Box 110650 Juneau, AK 9981100000-0650 Ph. 0000 Phone 000-000-0000 Fax 000- 000 000-0000 Provider Email Address xxxxxxxx.xxxxxx@xxxxxx.xxx Provider’s Federal Tax ID IRIS Pay Vendor Number xxxxxx.xxxxx@xxxxxx.xxxCheck Entity Type: Private For-profit Business, licensed to do business in the State of Alaska Non-Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement, a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA)

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants Grants, Contracts & Contracts Chief_ Facilities Chief Printed Name of Authorized Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxxxxx, Mental Health Clinician III Division of Behavioral Health PO Box 110620 Juneau, AK 00000-0000 Phone 000 000-0000 Fax 000 000-0000 xxxxxxxx.xxxxxxx@xxxxxx.xxx Provider’s Federal Tax ID Number - Do Not provide Social Security Numbers Provider Phone Number / Fax Provider Email Address ADMINISTRATIVE CONTACT Xxxxxxxx Xxxxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Grants Administrator Grants & Contracts Provider Email Address Support Team PO Box 110650 Juneau, AK 9981100000-0650 Ph. 0000 Phone 000-000-0000 Fax 000- 000 000-0000 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider’s Federal Tax ID IRIS Pay Vendor Number xxxxxx.xxxxx@xxxxxx.xxxCheck Entity Type: Private For-profit Business, licensed to do business in the State of Alaska Non-Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement, a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA)

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ days notice. A Provider may also terminate the Agreement with 30 days’ days notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providers, as directed by DHSS. The State is liable only for payment in accordance with notice must include the payment provision of this date on which the Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect as soon as the agreement is signed by both parties will cease to the agreementprovide BCHC Consultant/Resource services. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxxxx Xxxxxx, Grants & Contracts Chief_ Manager, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxxxx Xxxxxxx, BCHC Program Director Division of Public Health 000 “X” Xxxxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99503 Phone: (000) 000-0000 / Fax: (000) 000-0000 Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxx Xxxxxx, Xxxxxx Grants Administrator Grants & Contracts Provider Email Address Support Team PO Box 110650 Provider Contact Email Address Juneau, AK 9981100000-0650 Ph. 0000 Phone: (000-) 000-0000 Fax 000- / Fax: (000) 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx--AGREEMENT EFFECTIVE UPON COMPLETION OF BOTH PARTIES SIGNATURES--

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ days notice. A Provider may also terminate the Agreement with 30 days’ days notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providers, as directed by DHSS. The State is liable only for payment in accordance with notice must include the payment provision of this date on which the Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect as soon as the agreement is signed by both parties will cease to the agreementprovide BCHC Consultant/Resource services. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Manager, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxxx Xxxxx, BCHC Health Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx Associate Division of Public Health PO Box 240249 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99524 Phone: (000) 000-0000 / Fax: (000) 000-0000 Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxxxxxx Xxxxxxx, Xxxxxx Administrator Grants & Contracts Provider Email Address Support Team PO Box 110650 Provider Contact Email Address Juneau, AK 9981100000-0650 Ph. 0000 Phone: (000-) 000-0000 Fax 000- / Fax: (000) 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx--AGREEMENT EFFECTIVE UPON COMPLETION OF BOTH PARTIES SIGNATURES--

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ days notice. A Provider may also terminate the Agreement with 30 days’ days notice, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providers, as directed by DHSS. The State is liable only for payment in accordance with notice must include the payment provision of this date on which the Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect as soon as the agreement is signed by both parties will cease to the agreementprovide BCHC Screening services. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Manager, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxxx Xxxxx, BCHC Health Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx Associate Division of Public Health PO Box 240249 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99524 Phone: (000) 000-0000 / Fax: (000) 000-0000 Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxxxxxx Xxxxxxx, Xxxxxx Administrator Grants & Contracts Provider Email Address Support Team PO Box 110650 Provider Contact Email Address Juneau, AK 9981100000-0650 Ph. 0000 Phone: (000-) 000-0000 Fax 000- / Fax: (000) 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx--AGREEMENT EFFECTIVE UPON COMPLETION OF BOTH PARTIES SIGNATURES--

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx Xxxxxxx, Grants & Contracts Chief_ Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address Provider Phone Number/ Fax Number Provider Email Address Provider’s Federal Tax ID Number - Do Not List SSN Signature of DHSS Representative & Date Xxx Xxxxx Xxxxxx, Contracts & Facilities Chief Printed Name - DHSS Representative & Title DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxx Xxxxxx, Program Manager Alaska Psychiatric Institute Coordinator Division of Behavioral Health 0000 X Xxxxxx, Xxxxx Xxxxxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider Alaska 00000-0000 Phone Number/ Fax Number 000 000-0000 xxxx.xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Grants Administrator Grants & Contracts Provider Email Address Support Team PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-0000 xxxxxx.xxxxx@xxxxxx.xxx Provider’s Federal Tax ID IRIS Pay Vendor Number xxxxxx.xxxxx@xxxxxx.xxxCheck Entity Type: Private For-profit Business, licensed to do business in the State of Alaska Non-Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement, a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA)

TERMINATION OF AGREEMENT AND APPEALS. The Provider Consultant agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider Consultant eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider Consultant may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider Consultant may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Consultants, as soon as the agreement is signed directed by both parties to the agreementXXXX. This Agreement remains in force until the Provider Consultant or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider Consultant agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER CONSULTANT DEPT. OF HEALTH & SOCIAL SERVICES _ Signature of Authorized Provider Consultant Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants Grants, Contracts & Contracts Chief_ Facilities Chief Printed Name Provider Consultant Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxx Xxxxxxx, Health Program Manager Alaska Psychiatric Institute II Division of Behavioral Health 0000 Xxxxx Xxxxxx X Xx Xxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Provider 99503-5935 Ph. 000-000-0000 Fax 000-000-0000 Email: xxxx.xxxxxxx@xxxxxx.xxx DSM: xxxx.xxxxxxx@xxx.xxx.xxxxxxxx.xxx Consultant Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxx Xxxxxxx, Xxxxxx Grants Administrator Grants & Contracts Provider Support Team Consultant Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-000-0000 Provider’s Consultant Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxEmail: xxx.xxxxxxx@xxxxxx.xxx Consultant IRIS Vendor Number

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxxxx Xxxxxx, Chief Grants & Contracts Chief_ Printed Name - Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxxxxx Xxxxx, ASAP Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx Division of Behavioral Health 000 X. Xxxxxx/ASAP Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99501 Ph. 000-000-0000/Fax907-264-0786 xxxx.xxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxxxxx Xxxxxx, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxxxxxxxxxx.xxxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-non- payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxxxx Xxxxxx, Grants & Contracts Chief_ Manager Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx XxxxxxXxxx Xxxxx, Program Manager Alaska Psychiatric Institute DHSS Division of Behavioral Health 0000 X Xxxxxx Xxxxx Xxxxxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Alaska 99503-5935 Ph (000) 000-0000/FX (000) 000-0000 ADMINISTRATIVE CONTACT Xxxxxxxxx Xxxxxxx, Xxxxxx Administrator Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxx, Xxxxxx Administrator Grants & Contracts Provider Email Address Support Team PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx(000) 000-0000/FX (000) 000-0000 xxxxxxxxx.xxxxxxx@xxxxxx.xxx Providers must identify the business entity type under which they are legally eligible to provide service and intending to enter into this Provider Agreement.

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only notice but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute execute, and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants Grants, Contracts & Contracts Chief_ Facilities Chief Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxxxx, Program Manager Alaska Psychiatric Institute Xxxx Xxxxxxx-Xxxx Division of Behavioral Health 0000 X Xxxxxx Xxxxx Xxxxxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx 99501 000-000-0000 Xxxx.xxxxxxx-xxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxxxxx Xxxxxx, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-0000 Provider’s Federal Tax ID IRIS Vendor Number xxxxxx.xxxxx@xxxxxx.xxxxxxxxxxx.xxxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only notice but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute execute, and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx, Grants Grants, Contracts & Contracts Chief_ Facilities Chief Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxx Xxxxxxxxxxx, FASD Program Manager Office of Substance Misuse & Addiction Prevention 0000 X Xxxxxx, Program Manager Alaska Psychiatric Institute 0000 Xxxxx Xxxxxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Alaska 99503 xxxx.xxxxxxxxxxx@xxxxxx.xxx Ph. 907.334-2673/ 000-000-0000 Cell Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxxxxx Xxxxxx, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 / Fax 000- 000-0000 Provider’s Federal Tax ID IRIS Vendor Number xxxxxx.xxxxx@xxxxxx.xxxxxxxxxxx.xxxxxx@xxxxxx.xxx

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I of this Agreement. Notification of non- non-eligibility will result in automatic termination of this Agreement. Failure to comply with the terms of this Agreement and/or standards outlined in the Agreement and its appendices may result in non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.200. All appeals will be conducted in accordance with Section 7AAC 81.200-210 of the Alaska Administrative Code. Except as noted above, DHSS may terminate this Agreement with 30 days’ notice. A Provider may also terminate the Agreement with 30 days’ notice. The State is liable only , but must provide assistance in making arrangements for payment in accordance with the payment provision safe and orderly transfer of this Provider Agreement for relief nursing services rendered before the effective date of termination. This agreement shall be in effect clients and information to other Providers, as soon as the agreement is signed directed by both parties to the agreementDHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. I certify that I am authorized to negotiate, execute and administer this agreement on behalf of the Provider agency named in this agreement, and hereby consent to the terms and conditions of this agreement, and its appendices and attachments. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Authorized Provider Representative & Date Signature of DHSS Representative & Date Xxxxxxx XxxxxxxXxx Xxxxx Grants, Grants Contracts & Contracts Chief_ Facilities Chief Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxxxxx Xxxx Xxxxxx, Program Manager Alaska Psychiatric Institute Coordinator Division of Behavioral Health 0000 X Xxxxxx, Xxxxx Xxxxxx 000 Anchorage, AK 99508 xxxxxxxx.xxxxxx@xxxxxx.xxx Alaska 00000-0000 Phone 000 000-0000 xxxx.xxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxXxxxxxxx Xxxxxx, Xxxxxx Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Ph. 000-000-0000 Fax 000- 000-0000 Provider’s Federal Tax ID Number xxxxxx.xxxxx@xxxxxx.xxx- Do Not List SSN xxxxxxxx.xxxxxx@xxxxxx.xxx Provider’s IRIS Pay Vendor Number Check Entity Type: Private For-profit Business, licensed to do business in the State of Alaska Non-Profit Organization Incorporated in the State of Alaska, or tax exempt under 26 U.S.C. 501(c)(3) Alaska Native Entity, as defined in 7 AAC 78.950(1) All applicants under this provision must submit with their signed Agreement, a Waiver of Sovereign Immunity, using the form provided as Appendix D to this Provider Agreement. Political Subdivision of the State (City, Borough or REAA)