ContractContract for Local Health Jurisdiction • August 31st, 2018 • Washington
CONTRACTforLocal Health Jurisdiction HCA Contract Number: THIS AGREEMENT made by and between Washington State Health Care Authority, hereinafter referred toas "HCA," and the party whose name appears below, hereinafter referred to as the "Contractor." CONTRACTOR NAME CONTRACTOR doing business as (DBA) CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS IDENTIFIER (UBI) CONTRACTOR CONTACT CONTRACTOR TELEPHONE( ) CONTRACTOR E-MAIL ADDRESS HCA PROGRAMMedicaid Administrative Claiming (MAC) HCA DIVISION/SECTION HCA CONTACT NAME AND TITLE HCA CONTACT ADDRESS HCA CONTACT TELEPHONE HCA CONTACT E-MAIL ADDRESS IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF THIS CONTRACT?YES NO CFDA NUMBER(S)93.778 FFATA Form RequiredYES NO CONTRACT START DATE CONTRACT END DATE TOTAL MAXIMUM CONTRACT AMOUNT PURPOSE OF CONTRACT: The purpose of this Contract is to support Medicaid related outreach and linkage activities performed by Local Health Jurisdictions (LHJ) to Washington State residents who live within it
