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Health Services Authorization (BSA) Form <br />hm:,:l/www.-doh. Wl!...2 0.v/Portalsl ll.DocumenfS/Pub$!9.l 0-002-Anpro11edHS A .. doc x <br />Restrictions on Funds (wh.at run.ds can be used for which activities, not dinct payments, etc) <br />1. At. least 3 0% of federal Titl e V fund!! mus1 be ·~ for prcvcruive and primary c::are serv:i c es for children and at least 30% must be used services for children with <br />special health care needs, (Social Security law, Sec. 50 5(a)(3)]. <br />2. Funds may not be used for: <br />a. Inpatient services, other than inpatient services for childn:n with special health care needs or high risk pregnant women and infants, and other patient services approved by <br />Health Resources and Services Administration (HR.SA). <br />b. Cash payments to intended recipients of health services. <br />c. The purchase or improvement of land, the purchase, construction, or permanent improvement of any building or other facility, or the pw-chase of major medical <br />equipment. <br />d. Meeting other federal matching funds requirements. <br />e. Providing funds for research or training to any entity other than a public or nonprofit private entity. <br />f. payment for any services furnished by a provider or entity who has been excluded under Title XVIll (Medicare), Title XIX (Medicaid), or Title XX (social services block <br />grant).[Social Security Law, Sec 504(b)]. <br />3. If any charges are imposed for the provision of health services using Title V (MCH Block Grant) fimds, such charges will be pursuant to a public schedule of charges; will not <br />be imposed with respect to services provided to low income mothers or children; and will be adjusted to reflect the income, resources, and family size of the individual <br />provided the services. [Social Security Law, Sec. 505 (l)(D)). <br />Monitoring Visits (frequency, type) <br />Telephone calls with contract manager at least one every quarter, and annual site visit. <br />Special Billing Requirements <br />Payment is contingent upon DOH receipt and approval of all deliverables and an acceptable Al9-1A invoice voucher. Payment to completely expend the "Total Consideration" <br />for a specific funding period will not be processed until all deliverables are accepted and approved by DOH. Invoices must be submitted monthly by the 30th of each month <br />following the month in which the expenditures wen: incurred and must be based on actual allowable program costs. f3illing for services on a monthly fraction of the "Total <br />Consideration" will not be accepted or approved. <br />DOH Program Contact <br />MazyDussol <br />Community Consultant <br />Office of Family and Community Health Improvement <br />Washington State Department of Health <br />Street Address: 310 Israel Rd SE, Tumwater, WA 9850 l <br />Mailing Address: PO Box 47848, Olympia, WA 98504 <br />Telephone: 360-236-3781 /Fax: 360-236-3646 <br />Email: mary.dussol@doh.wa.gov <br />Exhibit A, Statements of Work Page 5 of28 Contract Number CLHI 8249