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Kittitas County <br />Review Form <br />Grants & Contract Agreement <br />Contract/G ra nt I nformation <br />Recommendation for Board of Health Review on <br />Department Head Signature Director Date >t 22 <br />Kittitas county Prosecutor, Auditor, and Board of Health Review and comment: <br />APP FOR <br />Signature of P or's Offi Date <br />Signature of Aud s Office Date <br />Verification the contracting Agency is not suspended/Disbarred: <br />Financial lnformation <br />Today's Date <br />t1.11712022 PA camas Request #: [1f}l \t <br />Fund/Department <br />L16-Public Health Agenda Date <br />Contract /Grant Agency: Health Care Autho rity-Medicaid Admatch Amendment 1 <br />Period Begin Date:January 1,,2021 Period End Date: December 31,2025 <br />Total Grant/Contract Amount: Fee for Service <br />Grant/Contract Number: K4649 <br />The Healthcare Authority Professional Services Contract is established to support Medicaid related <br />outreach and linkage activities performed by Kittitas County Public Health to Washington State residents <br />Contract/G ra nt Summary: <br />who live within Kittitas Coun <br />E Agency is not suspended/disbarred ! Not Checked (reason) <br />Grant/Contract Review Page 1