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Today's Date <br />04/23/2018 <br />Fund/Department <br />116 -Public Health <br />Kittitas County <br />Review Form <br />Grants & Contract Agreement <br />Agenda Date <br />ir.sW SFS---.�"p c. <br />KFTt TAS1 kIVY1V <br />Contract/Grant Information <br />Contract /Grant Agency: First Choice <br />Period Begin Date: Upon Signature Period End Date: Upon termination by either <br />party <br />Total Grant/Contract Amount: $ <br />Grant/Contract Number: <br />Contract/Grant Summary: <br />The agreement between Kittitas County Public Health Department and First Choice so the department <br />can bill patients health insurance for services provided. <br />Recommendation for Board of Health and Board of Health Review on <br />F <br />Department Head Signature: <br />Administrator Date: <br />Kittitas County Prosecutor, Auditor, and Board of Health Review and Comment: <br />APPROVED AS TO FORM: <br />Signature of Prosecutor's Office Date <br />Signature of Auditor's Office <br />Date <br />Signature of Board of Health member Date <br />Financial Information <br />Total Amount $ <br />State Funds $ <br />Federal Funds $ <br />Percentage County Funds <br />Matching Funds $ <br />CFDA# <br />In -Kind $ <br />Explain <br />ENE <br />Grant/Contract Review Page 1 <br />