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DocuSign Envelope ID: 984F2903-5D63-4284-67A2-A54B6EAAA057 <br />Contractor must submit properly itemized invoices to include the following information, as <br />applicable: <br />HCA Contract number K763-02; <br />Contractor name, address, phone number; <br />Description of Services; <br />Date(s) of delivery; <br />Net invoice price for each item; <br />Applicable taxes; <br />Total invoice price; and <br />Payment terms and any available prompt payment discount. <br />HCA will return incorrect or incomplete invoices to the Contractor for correction and <br />reissue. The Contract Number must appear on all invoices, bills of lading, packages, and <br />correspondence relating to this Contract. <br />5. Exhibit A. ABCD Quarterly Outreach & Case Management Report, is hereby replaced in its <br />entirety with Exhibit A2. <br />6. Exhibit B. Community Outreach and Coordination of Care Report, is hereby replaced in its <br />entirety with Exhibit B-2 <br />7. Exhibit D. Budget Tool, is hereby replaced in its entirety with Exhibit D-2. <br />8. HCA contact is Janice Tadeo, Dental Program Administrator at Janice.tadeo@hca.wa.gov. <br />9. This Amendment shall be effective July 1, 2017 ("Effective Date"). <br />10. All capitalized terms not otherwise defined herein have the meaning ascribed to them in the <br />Contract. <br />11. All other terms and conditions of the Contract remain unchanged and in full force and effect. <br />The parties signing below warrant that they have read and understand this Amendment and have <br />authority to execute the Amendment. This Amendment will be binding on HCA only upon signature <br />by HCA. <br />CONTRACTOR SIGNATURE <br />PRINTED NAME,AND TITLE <br />T <br />I <br />DATE SIGNED <br />HCA SIGNATURE <br />PRINTED NAME AND TITLE <br />DATE SIGNED <br />HCA Contract No. K763-02 Page 2 of 12 <br />