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AMENDMENT #4 Task *May Support PHAB Payment Number Task/ Activity/Description Standards/Measures Deliverables/Outcomes Due Date/Time Frame Information and/or Amount Jc Develop 2019-2020 MCHBG Action Plan for Submit MCHBG Action Plan to Draft August 17, 2019 must only reflect October 1, 2019 through September 30, 2020 DOH contract manager Final-September 5, activities paid for using DOH-:]Jrovided temylate. 2019 with funds provided 3d Report activities and outcomes of 2018-2019 Submit Action Plan monthly Monthly, on or before in this statement of MCHBG Action Plan using DOH-provided reports to DOH contract manager the 15 1 " of the following work for the template. month specified funding period. See Program Specific Requirements and Special Billing Requirements. Children with Special Health Care Needs (CSHCN) 4a Complete Child Health Intake Form (CHIF) Submit CHIF data into Secure File January 15 , 2018 Reimbursement for using the CHIF Automated System on all infants Transport (SFT) website : April 15,2018 actual costs, not to and children served by the CSHCN Program as https:/ /sft. wa.gov July 15 , 2018 exceed total funding referenced in CSHCN Program Manual. October 15, 2018 consideration. Ensure client data is collected on all children January 15, 2019 Action Plan and served by CSHCN contractors , including April 15, 2019 Progress Reports neurodevelopmental centers, regional July 15, 2019 must only reflect maxillofacial coordinators, and the DOH activities paid for Newborn Screening Program. with funds provided 4b Administer requested DOH Diagnostic and Submit completed Health Services 30 days after forms are in this statement of Treatment funds for infants and children per Authorization forms and Central completed. work for the CSHCN Program Manual when funds are used. Treatment Fund requests directly specified funding to the CSHCN Program as needed. period. 4c Participate in the CSHCN Regional System and Submit Action Plan monthly Monthly, on or before quarterly meetings as described in the CSHCN reports including number of the 15 th of the following See Program Pn~gnm, Me1m-m Focus of Work . regional meetings attended to the month Specific DOH contract manager. Requirements and 4d Develop and update CYSHCN County Resource Submit completed resource list September 30, 2019 Special Billing List and share with partners as described in the electronically to the DOH contract Requirements. CSHCN Focus of Work. manager. *For Information Only: Funding is not tied to the revised Standards/M easures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at : hrtp :// ww-w .phaboard. org/,.,P:contentfuploads/PHAB-Standards-and-.M.easures-Version-J . O.pd! Program Specific Requirements/Narrative Exhibit A , Statements of Work Revised as of July 16, 2018 Page 9 of32 Contract Number CLH18249-4