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 81.205. All appeals will be conducted in accordance with Section 7AAC 81.205-210 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, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providers, as directed by DHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Provider Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxx Xxxxx, Behavioral Health Emergency Services Coordinator Division of Behavioral Health 0000 “X” Xxxxxx, Xxxxx 000 Anchorage, AK 99503 D: (000) 000-0000; (000) 000-0000 ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx Xxxxxx, Grants Administrator Grants & Contracts Support Team PO Box 110650 Juneau, AK 99811-0650 Federal Tax ID Number Xxxxxx.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- non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.20581.200. All appeals will be conducted in accordance with Section 7AAC 81.20581.200-210 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. 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 Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxx Xxxxx, Behavioral Health Emergency Services Coordinator Division of Behavioral Health 0000 “X” Xxxxxxxx Xxxxxx, Administrative Assistant III Alaska Psychiatric Institute 0000 Xxxxx 000 Xxxxxx Anchorage, AK 99503 D: (000) Alaska 99508-4677 000-0000; (000) 000-0000 ADMINISTRATIVE CONTACT / Fax 000-000-0000 Provider Phone Number/ Fax Number ADMINISTRATIVE CONTACT Xxxxxx XxxxxxXxxxx, Grants Administrator Grants III _ Dept. of Health & Contracts Support Team PO Social Services Provider Email Address P.O. Box 110650 Juneau, AK 99811-0650 _ Ph. 000-000-0000 / Fax 000- 000-0000 Provider’s Federal Tax ID Number Xxxxxx.Xxxxxx@xxxxxx.xxxNumber

TERMINATION OF AGREEMENT AND APPEALS. The Provider agrees to notify DHSS FCS 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 DHSSFCS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.20581.200. All appeals will be conducted in accordance with Section 7AAC 81.20581.200-210 of the Alaska Administrative Code. Except as noted above, DHSS FCS 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 ProvidersProvider assigned practitioners, as directed by DHSSFCS. This Agreement remains in force until the Provider or DHSS FCS terminates the Agreement or a material term of the Agreement is changed. PROVIDER DEPT. DEPT OF HEALTH FAMILY & SOCIAL COMMUNITY SERVICES Signature of Provider Representative & Date Signature of DHSS DFCS Representative & Date Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Xxxx Xxxxxxxx, Division Operations Manager Provider Contact & Mailing Address DHSS DFCS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Attn: API Contracts Office 0000 Xxxxx Xxxxx, Behavioral Health Emergency Services Coordinator Division of Behavioral Health 0000 “X” Xxxxxx, Xxxxx 000 Xxxxxx Anchorage, AK 99503 D: (000) 00099508-0000; (000) 000-0000 3700 xxx.xxx.xxxxxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx XxxxxxXxxxxxxxxx Xxxxxxx, Grants Administrator Grants & Contracts Support Team PO Family and Community Services P.O. Box 110650 Juneau, AK 99811-0650 112650 Federal Tax ID Number Xxxxxx.Xxxxxx@xxxxxx.xxxJuneau, AK 00000-0000 Phone (000) 000-0000 Fax (000) 000-0000 Xxxxxxxxxx.Xxxxxxx@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 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- 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 81.20581.200. All appeals will be conducted in accordance with Section 7AAC 81.20581.200-210 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, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providersservice providers, as directed by DHSS. This Agreement remains in force until the Provider Consultant or DHSS terminates the Agreement or a material term of the Agreement is changed. PROVIDER CONSULTANT DEPT. OF HEALTH & SOCIAL SERVICES Signature of Provider Consultant Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Xxxxxx -DHSS Representative Division Chief, G&CST Grants & Contracts Printed Name Provider Consultant Representative & Title Printed Name - DHSS Representative & Title Provider Support Team Consultant Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxx XxxxxXxxx Xxxxxxxx, Behavioral Mental Health Emergency Services Coordinator Clinician III Division of Behavioral Health 0000 “X” XxxxxxX Xx., Xxxxx 000 Anchorage, AK 99503 D: (000Phone(907) 000-0000; 0000 / Fax (000) 000-0000 ADMINISTRATIVE CONTACT Provider Consultant Phone Number/ Fax Number Consultant’s Federal Tax ID Number ADMINISTRATIVE CONTACT Xxxxxx Xxxxxx, Grants Administrator Grants & Contracts Support Team PO Box 110650 Juneau, AK 99811-0650 Federal Tax ID Number Xxxxxx.Xxxxxx@xxxxxx.xxx(000) 000-0000 / Fax (000) 000-0000 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 immediately if it is no longer eligible to provide services based on applicable Provider eligibility requirements set out in Section I and Section IV.9 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- non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.20581.200. All appeals will be conducted in accordance with Section 7AAC 81.20581.200-210 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, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other ProvidersProvider assigned physicians, as directed by DHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. PROVIDER DEPT. DEPT OF HEALTH & SOCIAL SERVICES Signature of Provider Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant 0000 Xxxxx Xxxxx, Behavioral Health Emergency Services Coordinator Division of Behavioral Health 0000 “X” Xxxxxx, Xxxxx 000 Xxxxxx Anchorage, AK 99503 D: (000) 000Alaska 99508-0000; (000) 000-0000 3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx XxxxxxXxxxx, Grants Administrator Grants & Contracts Support Team PO P.O. Box 110650 Juneau, AK 99811-0650 Federal Tax ID Number Xxxxxx.Xxxxxx@xxxxxx.xxxJuneau, AK 00000-0000 Phone (000) 000-0000 Fax (000) 000-0000 xxxxxx.xxxxx@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- payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.20581.200. All appeals will be conducted in accordance with Section 7AAC 81.20581.200-210 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 ProvidersProvider assigned practitioners, as directed by DHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. PROVIDER DEPT. DEPT OF HEALTH & SOCIAL SERVICES Signature of Provider Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & &Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant 0000 Xxxxx Xxxxx, Behavioral Health Emergency Services Coordinator Division of Behavioral Health 0000 “X” Xxxxxx, Xxxxx 000 Xxxxxx Anchorage, AK 99503 D: (000) 000Alaska 99508-0000; (000) 000-0000 3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx XxxxxxXxxxxxxxx Xxxxxxx, Grants Administrator Grants & Contracts Support Team PO P.O. Box 110650 Juneau, AK 99811-0650 Federal Tax ID Number Xxxxxx.Xxxxxx@xxxxxx.xxxJuneau, AK 00000-0000 Phone (000) 000-0000 Fax (000) 000-0000 Xxxxxxxxx.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- 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 DHSSDFCS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.20581.200. All appeals will be conducted in accordance with Section 7AAC 81.20581.200-210 of the Alaska Administrative Code. Except as noted above, DHSS DFCS 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 Clients and information to other Providers, as directed by DHSSDFCS. 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 DFCS Representative & Date Xxxxx XxxxxxXxxxxx Xxxxx, Chief, G&CST Grants & Contracts Chief Printed Name Provider Representative & Title Printed Name - DHSS DFCS Representative & Title Provider Contact & Mailing Address DHSS DFCS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxx XxxxxXxxxxxx, Behavioral Health Emergency Services Coordinator Division of Behavioral Health Chief Financial Officer Alaska Psychiatric Institute 0000 “X” Xxxxxx, Xxxxx 000 Xxxxxx Anchorage, AK 99503 D: (000) 000-0000; (000) 000AK, 00000-0000 ADMINISTRATIVE CONTACT Phone 000.000.0000 Fax 000.000.0000 xxxxx.xxxxxxx@xxxxxx.xxx Provider Phone Number/ Fax Number Xxxxxx XxxxxxADMINISTRATIVE CONTACT Xxxxx Xxxxxxxx, Grants Administrator Grants & Contracts Support Team Provider Email Address PO Box 110650 Juneau, AK 99811-0650 Federal Tax ID Ph. 000-000-0000 Fax 000-000-0000 Provider’s IRIS Vendor Number Xxxxxx.Xxxxxx@xxxxxx.xxxQuestions on the PA: xxxxx.xxxxxxxx@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- payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.205. All appeals will be conducted in accordance with Section 7AAC 81.205-210 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, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other Providers, as directed by DHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. PROVIDER DEPT. OF HEALTH & SOCIAL SERVICES Signature of Provider Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Xxxxx Xxxxxxx X. Xxxxx, M.S., Behavioral Health Emergency Services Coordinator Program Specialist Division of Behavioral Health 0000 “X” Xxxxxx, Xxxxx 000 Anchorage, AK 99503 DP: (000) 000-0000; (000) 000-0000 ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx XxxxxxXxxxx Xxxxx, Grants Administrator Grants & Contracts Support Team PO Box 110650 Juneau, AK 99811-0650 Federal Tax ID Number Xxxxxx.Xxxxxx@xxxxxx.xxx0650

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 and Section IV.9 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- non-payment and automatic termination of the Agreement by DHSS. A Provider may appeal the decision to terminate a Provider Agreement under 7 AAC 81.20581.200. All appeals will be conducted in accordance with Section 7AAC 81.20581.200-210 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, but must provide assistance in making arrangements for safe and orderly transfer of clients and information to other ProvidersProvider assigned physicians, as directed by DHSS. This Agreement remains in force until the Provider or DHSS terminates the Agreement or a material term of the Agreement is changed. PROVIDER DEPT. DEPT OF HEALTH & SOCIAL SERVICES Signature of Provider Representative & Date Signature of DHSS Representative & Date Xxxxx Xxxxxx, Chief, G&CST Printed Name Provider Representative & Title Printed Name - DHSS Representative & Title Provider Contact & Mailing Address DHSS Contacts & Mailing Addresses PROGRAM CONTACT Alaska Psychiatric Institute Xxxxxxxx Xxxxxx Administrative Assistant 0000 Xxxxx Xxxxx, Behavioral Health Emergency Services Coordinator Division of Behavioral Health 0000 “X” Xxxxxx, Xxxxx 000 Xxxxxx Anchorage, AK 99503 D: (000) 000Alaska 99508-0000; (000) 000-0000 3700 Xxxxxxxx.Xxxxxx@xxxxxx.xxx ADMINISTRATIVE CONTACT Provider Phone Number/ Fax Number Xxxxxx XxxxxxXxxxx, Grants Administrator Grants & Contracts Support Team PO P.O. Box 110650 Juneau, AK 99811-0650 Federal Tax ID Number Xxxxxx.Xxxxxx@xxxxxx.xxxJuneau, AK 00000-0000 Phone (000) 000-0000 Fax (000) 000-0000