ContractContract Qualified Health Homes • September 27th, 2017 • Washington
CONTRACTQualified Health Homes HCA Contract Number: «HCA_K_» Resulting from Solicitation Number (If applicable): Contractor/Vendor 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 «Kr_Name» CONTRACTOR doing business as (DBA) «Kr_DBA» CONTRACTOR ADDRESS«Mailing_Address»«Kr_City», «Kr_City» «Kr_Zip_Code» WASHINGTON UNIFORM BUSINESS IDENTIFIER (UBI) CONTRACTOR CONTACT«Kr_Contact» CONTRACTOR TELEPHONE«Kr_Telephone» CONTRACTOR E-MAIL ADDRESS«Kr_Email» HCA PROGRAMQualified Health Homes HCA DIVISION/SECTIONMPOI/GPD HCA CONTACT NAME AND TITLE Agnes Ericson HCA CONTACT ADDRESSPost Office Box 45530 Olympia, WA 98504-5530 HCA CONTACT TELEPHONE(360) 725-1115 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 ST
