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Task <br />Activity <br />Deliverables/Outcomes <br />Due Date/Time Frame <br />Payment Information and/or <br /># <br />Amount <br />2a <br />Report activities and outcomes of 2022 MCHBG Action <br />Submit quarterly Action Plan reports to <br />January 15, 2022 <br />Reimbursement for actual costs, <br />Plan using DOH- provided template. <br />DOH Contract manager <br />April 15, 2022 <br />not to exceed total funding <br />July 15, 2022 <br />consideration. Action Plan and <br />Progress Reports must only reflect <br />2b <br />Develop 2022-2023 MCHBG Action Plan for October 1, <br />Submit MCHBG Action Plan to DOH <br />Draft August 19, 2022 <br />2022 through September 30, 2023 using DOH -provided <br />contract manager <br />Final- September 9, <br />activities paid for with funds <br />template. <br />2022 <br />provided in this statement of work <br />for the specified funding period. <br />See Program Specific <br />Requirements and Special Billing <br />Requirements. <br />Children and Youth with Special Health Care Needs(CYSHCN) <br />3a <br />Complete Child Health Intake Form (CHIF) using the <br />Submit CHIF data into Secure Access <br />January 15, 2022 <br />Reimbursement for actual costs, <br />CHIF Automated System on all infants and children served <br />Washington website: <br />April 15, 2022 <br />not to exceed total funding <br />by the CYSHCN Program as referenced in CYSHCN <br />https://secureaccess.wa.2ov <br />July 15, 2022 <br />consideration. Action Plan and <br />Pro am avidance. <br />Progress Reports must only reflect <br />activities paid for with funds <br />3b <br />Identify unmet needs for CYSHCN on Medicaid and refer <br />Submit completed Health Services <br />30 days afterforms are <br />to DOH CYSHCN Program for approvalto access <br />Authorization forms and Central <br />completed. <br />provided in this statement of work <br />Diagnostic and Treatment funds to meet the need. <br />Treatment Fund requests directly to the <br />for the specified funding period. <br />CYSHCN Program asneeded. <br />See Program Specific <br />3c <br />Work with partnersto share updated local CYSHCN <br />Review resources for yourlocal area on <br />September30, 2022 <br />resources with Within Reach / Help Me Grow (HMG). <br />ParentHelp 123.org annually for accuracy <br />Requirements and Special Billing <br />and submit any updates to Within Reach. <br />Requirements. <br />DOH Program and Fiscal Contact Information for all ConCon SOWS can be found on the DOH Finance SharePoint site. Questions related to this SOW, or any other <br />finance -related inquiry, may be sent to finance c&doh.wa.gov. <br />Federal Funding Accountability and Transparency Act (FFATA) (Applies to federal subrecipient funding.) <br />This statement of work is supported by federa I funds that require compliance with the Federal Funding Accountability and Trans parency Act (FFATA or the Transparency Act). <br />The purpose of the Transparency Act is to make information available online so the public can see how the federal funds are spent. <br />To comply with this act and be eligible to perform the activities in this statement of work, the LHJ must have a Data Univers al Numbering System (DUNS®) number. <br />Information about the LHJ and this statement of work will be made available onUSASpendinggov by DOH as required by P.L. 109-282. <br />Program Specific Requirements <br />Program Manual, Handbook, Policy References: <br />Children and Youth with Special Health Care Needs Manual - <br />https: //www.doh.wa.gov/ForPublicHea lthandHealthcareProviders/PublicHea lthSystemResourcesandServices/Loca 1HealthResourcesandTools/MatemalandChildHealthBlockGrant/ <br />ChildrenandYouthWithSpecialHealthCareNeeds <br />Health Services Authorization (HSA) Form <br />http: //www.doh.wa. gov/Porta ls/ 1 /Documents/Pubs/910-002-Api2rovedHSA.docx <br />Exhibit A, Statement of Work Page 2 of 3 Contract NumberCLH31015 <br />Template Created September 2021 <br />