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Payment Information analoFAmount2aReport activities andoutcomes of 2022 MCHBG ActionSubmit qua rterly ActionDOH ContractmanagerPIan using DOH- provided template.Plan reports toJanuary 15,2022Apnl 15,2022Reimbursement for a ctua I costs,not to exceed total fundingconsideration, Action Plan andProgress Reports must only reflectactivities paid for with fundsprovided in this statement of workfor the specified funding period.See Program Specific2bDevelop2022-2023MCHBGt5ActionPlanfbrOctoberISubmit MCHBGcontractmanagerAction Plan to DOHDraflAugust 19,2022Final- Septemberg,20222022throughSeptemberJ0,2023usmgDOH-providedtemplate.Requirements and Special Bilingand Youth withHealth Care NeedsdataAccess75,2CHIF Automated System on all infants and children servedWashington website:https: //secureaccess.wa.sovApnl 15,2O22July 15,2022by the CYSHCN Program as referenced in CYSHCNnot to exceed total fundingconsideration. Action Plan andProgress Reports must only reflectactivities paid for with fundsprovided in this statement ofworkfor the specified funding period.unmeton Medicaid acompHeaforms areto DOH CYSHCN Progam forapprovaltoaccessDiagnostic and Treatment funds to meet the need.Authorization fomrs and Centralcompleted.TreatmentFundrequestsdirectlytotheCYSHCNasneeded.3cWork withpartners to share updated local CYSHCNReview resources for your local area onSeptember30, 2022See Program SpecificRequirements and Special B illingresources with Within Reach/ Help Me Grow (HMG).llvforaccuracyandtestoReach.Due Date/Time FrameDeliverables/Outco mesActivityTask#Dorr Program and tr'iscal contact rnformation for all concon Sows can be found on the DoH Finance sharepoint site. euestions related to this sow, or any otherfinance-related inquiry, may be sent to finance@doh.wa.govEglblEundins Accountabilitv and Transparency Act (FFATA'I (Applies to federal subrecipient funding.)This statement of work is supported by federalfundt tnat tequite co-pliance with the Federal Funding Alcouliliiity and rransparency Act (FFATA or the Transparency Act).The purpose of the Transparency Act is to make information available online so the pubticcan r". fro* tft. federalfulds ar" ,p"nt.To comply with this act and be eligible to perform the activities in this statement ofwork, the LHJ must have a Data Univers al Numbering System (DuNS@) number.InformationabouttheLHJandthisstatementofworkwillbemadeavailableonuSASoending.eovbyDoHasrequiredbyp.L. log-2g2.Pro gram Specific ReouirementsProgram Manual, Handbook, Policy References:Children and Youth with Special Health Care Needs Manual -ChildrenandYouthWith Sp ecia lHea lthC a reNeedsHealth Services Authorization (IISA) Formhttp://rvrvw.doh.ua.eov/Portals/1/Documents/pubs/910{02-AoprovedHSA.docxExhibit A, Statement of WorkTemplate Created Septemb er202lPage 2 of 3Contract NumberCLH3 I 0 I 5