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I <br />Task Task! ActivitylDescription Number <br />2 Enroll new providers. Conduct an enrollment site <br />visit to all new providers, and gather information <br />needed to complete Program enrollment <br />Exhibit A , Statements of Work <br />Revised as of May 15,2017 <br />*May Support PHAB Deliverables/Outcomes StandardslMeasures <br />I <br />Provider Agreement for <br />Receipt of State Supplied <br />Vaccine with original <br />signature -DOH 348-002 <br />(NOTE: a photocopy will not <br />be accepted) <br />Page 4 of 10 <br />-----AMENDMENT #12 <br />Payment Information Due Date/Time Frame and/or Amount <br />Funds available for this <br />task*: <br />January 2017- <br />March 2017 <br />FFY16 PPHF 317 Ops- <br />74110267 <br />April 2017 - <br />December 2017 <br />FFY17 AFIX- <br />741102 75 <br />*See Restrictions on <br />Funds below <br />Within ten (10) days after Reimbursement for <br />the date of the provider actual costs incurred, <br />enrollment visit not to exceed total <br />funding consideration <br />amount. <br />Funds available for this <br />task*: <br />January 2017 - <br />March 2017 <br />FFY16 PPHF 317 Ops- <br />74110267 <br />April 2017 - <br />December 2017 <br />FFY17 AFlX- <br />74110275 <br />*See Restrictions on <br />Funds below <br />Contract Number C17114-12