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DocuSign Envelope ID: 4166FC64-6496-4305-B555-38A174BDAA73 <br />Washi ngton State <br />Hea lth Care -utho rity <br />PROFESSIONAL SERVICES <br />CONTRACT for HCA Contract Number: K3069 <br />MEDICAID ADMINISTRATIVE <br />CLAIMING <br />THIS CONTRACT is made by and between Washington State Health Care Authority, (HCA) and Kittitas <br />County Health Dept., (Contractor). <br />CONTRACTOR NAME K,N ,~C,.,. CONTRACTOR DOING BUSINESS AS CDBAl <br />Kittitas County Health Dept. <br />CONTRACTOR ADDRESS I Street City I State I Zip Code <br />507 N. Nanum Street, Suite 102 Ellensburg WA 98926 <br />CONTRACTOR CONTACT I CONTRACTOR TELEPHONE I CONTRACTOR E-MAIL ADDRESS <br />Liz Whitaker (509) 962 7068 liz.whitaker@co .kittitas.wa.us <br />Is Contractor a Subreciolent under this Contract? I CFDA NUMBER(S): I FFATA Form ReQuired <br />181YES •NO 93.778; 181YES ONO <br />HCA PROGRAM HCA DIVISION/SECTION <br />Medicaid Administrative Claiming (MAC) MPOI/CS <br />HCA CONTACT NAME AND TITLE HCA CONTACT ADDRESS <br />Health Care Authority <br />Jon Bragger 626 8th Avenue SE <br />Medical Assistance Program Specialist P0Box45506 <br />Olympia, WA 98504-5506 <br />HCA CONTACT TELEPHONE HCA CONTACT E-MAIL ADDRESS <br />(360) 725-1647 jon.brogger@hca.wa .gov <br />CONTRACT START DATE CONTRACT END DATE TOTAL MAXIMUM CONTRACT AMOUNT <br />January 1, 2019 December 31, 2020 No Maximum <br />PURPOSE OF CONTRACT: <br />The purpose of this Contract is to support Medicaid related outreach and linkage activities performed by Local Health <br />Jurisdictions (LHJ) to Washington State residents who live within its jurisdiction. These activities assist residents who <br />have no or inadequate medical coverage, and includes explaining the benefits of the Medicaid program, assisting them <br />in the Medicaid application and renewal processes, and linking them to Medicaid covered services . This Agreement <br />provides a process for partially reimbursing the Contractor for allowable and reasonable expenses associated with the <br />time its staff spend performing ~edicaid Administrative Claiming (MAC) activities. <br />The parties signing below warrant that they have read and understand this Contract, and have authority to <br />execute this Contract. This Contract will be binding on HCA only upon signature by HCA. <br />Rev 4/20/2017 <br />PRINT ED NAM E AND TITLE <br />r1 ~ LJmh, r¼mwn.s~ <br />PRINTED NAME AND TITLE <br />Annette schuffenhauer <br />chief Legal officer <br />DATE SIGNE D <br />\2 Z1 /8 <br />DATE SIG NED <br />2/28/2018