HomeMy WebLinkAboutCAG2019-1007 - Amendment - #1 - Public Health Seattle & King County (PHSKC) - Medicaid Administrative Claiming (MAC) Agreement # 4909 CHS Extension - 01/01/2021 FOR CITY OF KENT OFFICIAL USE ONLY
Sup/Mgr:
Agreement Routing Form Dir Asst:
• For Approvals,Signatures and Records Management Dir/Dep:
KE N T This form combines&replaces the Request for Mayor's Signature and Contract Cover Sheet forms. (Optional)
WA S H I N G T O N
Originator: Department:
KateLynn Jennings for Lori Guilfoyle Parks, Recreation & Community Services
Date Sent: Date Required:
> 04/20/2023
0
CL Authorized to Sign: Date of Council Approval:
C Director or Designee Mayor N/A
Budget Account Number: Grant?[:]YesZNo
10006370.64150.4690
Budget?R]YesEl No Type: N/A
Vendor Name: Category:
Public Health - Seattle King County Contract
Vendor Number: Sub-Category:
= 35625 Amendment
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Project Name: Medicaid Administrative Claiming Agreement - Amendment 1
E
Project Details:PHSKC will subcontract with City of Kent partner Children's Therapy Center to provide the Children with Special Needs program.
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C
4) Agreement Amount: $62,500 Basis for Selection of Contractor: Other
47 `Memo to Mayor must be attached
3- Start Date: 10/1/2019 Termination Date: 12/31/2022
Im
Q Local Business?P1]YesF_1No* If meets req uiremen ts per KCC 3.70.100,please complete"Vendor Purchase-Local Exceptions'form on Cityspace.
Business License Verification:Yes Elln-Process ElExempt(KCC 5.01.045)
Notice required prior to disclosure? Contract Number:
FlYesF]No CAG2019-1007
Comments:
See CAG2019-090 for agreement with Children's Therapy Center.
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4) y
•> i
N
OC a3, Date Received by City Attorney: N/A
R
Date Routed to the Mayor's Office: N/A
N
Date Routed to the City Clerk's Office: 4/20/2023
ac00)373_-_70 Visit Documents.KentWA.gov to obtain copies of all agreements
rev.20200218
DocuSign Envelope ID: 88F7CC99-6D60-4B2C-BD99-CDC55F9E8677
Public Health
Seattle & King County LQ
PHSKC Agreement # 4909 CHS —Amendment 1
AMENDMENT
This Amendment between PHSKC and the City of Kent changes the referenced Agreement for the following
purpose(s): This amendment extends the agreement through 12/31/2022 and adds funding.
Other Party: City of Kent, 220 4th Avenue South, Kent, WA 98032
Project Title: Medicaid Administrative Claiming
Effective Date of Amendment: January 1, 2021
1. Agreement Period is changed to 10/1/2019— 12/31/2022
2. Section V is revised to have an end date of December 31, 2022.
3. The maximum allocation amount in Exhibit I, Section III, is changed to read $112,500.
All other terms and conditions of the referenced Agreement and any previous Agreement amendment not
revised herein shall remain unchanged and in full force and effect.
CITY OF KENT SIGNATURE PRINTED NAME AND TITLE DATE SIGNED
DocuSigned by: Julie Parascondola 4/20/2021
�Zt. ratrxsovuh(A Director of Parks, Recreation and Community Services
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PHSKC SIGNATURE PRINTED NAME AND TITLE DATE SIGNED
Docusigned by: TJ Cosgrove 4/20/2021 CHS Division Director
59FFF98815384E0...
CTC CONCURRENCE SIGNATURE PRINTED NAME AND TITLE DATE SIGNED
Docu'Signed by: Janet Zamzow Bliss 4/14/2021
�aut t,{ '�Ou ,6W eCSS Janet Zamzow Bliss