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Task <br />Number <br />3c <br />Task/ Activity/Description *May Support PHAB <br />Standards/Measures Deliverables/Outcomes <br />AMENDMENT #6 <br />Payment <br />Due Date/Time Frame I Information and/or <br />Amount <br />Develop 2019-2020 MCHBG Action Plan for Submit MCHBG Action Plan to Draft August 17 , 2019 must only reflect <br />October 1, 2019 through September 30 , 2020 DOH contract manager Final-September 5, activities paid for <br />using DOH-_provided template. 2019 with funds provided <br />3d I Report activities and outcomes of 2018-2019 Submit Action Plan monthly Monthly, on or before in this statement of <br />MCHBG Action Plan using DOH-provided reports to DOH contract manager the 15 th of the following work for the <br />template. month specified funding <br />period. <br />See Program <br />Specific <br />Requirements and <br />Special Billing <br />Requirements . <br />Children with Special Health Care Needs (CSHCN) <br />4a Complete Child Health Intake Form (CHIF) Submit CHIF data into Secure File January 15, 2018 Reimbursement for <br />using the CHIF Automated System on all infants Transport (SFT) website : April 15, 2018 actual costs, not to <br />and children served by the CSHCN Program as https://sfl.wa .gov July 15, 2018 exceed total funding <br />referenced in CSHCN Program Manual. October 15, 2018 consideration. <br />Ensure client data is collected on all children January 15 , 2019 Action Plan and <br />served by CSHCN contractors , including April 15, 2019 Progress Reports <br />neurodevelopmental centers , regional July 15 , 2019 must only reflect <br />maxillofacial coordinators, and the DOH activities paid for <br />Newborn Screening Program. with funds provided <br />4b I Administer requested DOH Diagnostic and Submit completed Health Services 30 days after forms are in this statement of <br />Treatment funds for infants and children per Authorization forms and Central completed. work for the <br />CSHCN Program Manual when funds are used. Treatment Fund requests directly specified funding <br />to the CSHCN Program as needed. period. <br />4e · --&bmit Acti0n Plan m0Rthly l,WR f.Wj·, 0,'l er befeFI! D 1 · • · I ~ .«F~ieipaw ui uef-lCNRegiem:1 1 Sys .tem--(H-H/ <br />quar1erly mee~inr:s RS de.ser.ilied i11 .•.l.ze CSHC:V <br />FeeusefW0rk <br />ns iRl!htding ,'lwl'lher ef lhe---JJ.flt 0fthe _,"0U0wiRg See Program <br />regienal R1ee1h1gs auCRded te ~he memh Specific <br />1 DOH C.(N!lf'8 e t ,"Hfm&ge,:_. Requirements and <br />4d I Del•elep and a'fJrle:e CYSHCN UJ!-mty J?.e5el{.ree -I l &bmit c0m-pkted 1'8601,wce list Sepff!me<w 30. 20.79 Speci~l Billing <br />lisl e11d she re wit,', µrm~cseribed l,1 :./.ie I ek~fffle~ Requirements. <br />CSHC.VF0cus 0(Work. <br />*For Information Only: <br />Funding is not tied to the revised Standards/Measures listed here. This information may be helpful in discussions of how program activities might contribute to meeting a <br />Standard/Measure. More detail on these and/or other Public Health Accreditation Board (PHAB) Standards/Measures that may apply can be found at: <br />hnp://www.pbaboard .org/v.'P:cgntent/uploads/PHAB-Standards-and-Measures-Version-1 .0.pdf <br />Program Specific Requirements/Narrative <br />Exhibit A, Statements of Work <br />Revised as of November 15, 2018 <br />Page 5 of7 Contract Number CLH18249-6