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Exhibit A, Statements of WorkRevised as ofSeptember 15,2020AMENDMENT #17PaymentInformation and/orAmountmust only reflectactivities paid forwith funds providedin this statement ofwork for thespecified fundingperiod.See ProgramSpecificRequirements andSpecial BillingRequirements.Children and Youth with Special Health Care Needs (CYSHCN)Reimbursement foractual costs, not toexceed total fundingconsideration.Action Plan andProgress Reportsmust only reflectactivities paid forwith funds providedin this statement ofwork for thespecified fundingperiod.See ProgramSpecificRequirements andSpecial BillingRequirements.Due Date/Time FrameDraft August 17,2019Final- September 5,2019Monthly, on or beforethe 15th ofthe followingmonthDraft August 16,2020Final September 6,2020Monthly, on or beforethe 15th ofthe followingmonthOctober 15,2020January 15,2021April 15,2021Julv 15, 2021Draft August 20, 2021Final September 10,202 IJanuary 15,2018April 15,2018July 15,2018October 15,2018January 15,2019April 15,2019July 15,2019October 15,2019January 15,2020April 15,2020July 15,2020October 15,2020January 15,2021April 15,2021Julv 15,202130 days after forms arecompleted.Deliverables/OutcomesSubmit MCHBG Action Plan toDOH contract managerSubmit Action Plan monthly reportsto DOH contract managerSubmit MCHBG Action Plan toDOH contract managerSubmit Action Plan monthly reportsto DOH contract managerSubmit Action Plan reports to DOHcontracl managerSubmit MCHBG Action Plan toDOH contract managerSubmit CHIF data into Secure 4k@ Access Lf/ashingtonwebsite: l*#4ftt+a=se+https : //se c ure ac c es s.w a. g ovSubmit completed Health ServicesAuthorization forms and CentralTreatment Fund requests directly tothe CYSHCN Program as needed.*May Support PHABStandards/MeasuresTask/Activity/DescriptionDevelop 2019-2020 MCHBG Action Plan forOctober 1,2019 through September 30,2020using DOH-provided template.Report activities and outcomes of 2018-2019MCHBG Action Plan using DOH- providedtemplate.Develop 2020-2021 MCHBG Action Plan forOctober 7,2020 through September 30,2021using DOH-provided template.Report activities and outcomes of 2019-2020MCHBG Action Plan using DOH- providedtemplate.Report activities and outcomes of 2020-2 IMCHBG Action Plan using DOH-Providedtemplate.Develop 202 l-2022 MCHBG Action PlanforOctober I, 2021 through September 30, 2022us i ng D O H - Pr ovide d te mp I at e.Complete Child Health Intake Form (CHIF)using the CHIF Automated System on all infantsand children served by the CYSHCN Program asreferenced in CYSHCN Program MMguidance.Ensure client data is collected on all childrenserved by CYSHCN contractors,lnelud:.rngegionalmaxillofacial coordinators, and the DOHNewbom Screening Program.eYSHeN Pregrarn tr{atual vhenfunds are ased,Identifu unmet needsfor CYSHCN on Medicaid,and refer to DOH CYSHCN Prosram forTaskNumber3c3d3e3f3g3h4a4bPage 22 of 42Contract Number CLHI 8249 - 17