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DocuSign Envelope lD'. 7 C237 4F6-A621 -4812-836E-C9F031 F54785 <br />ii. Date of birth <br />iii. Provider One #, SSN or another unique identifier <br />iv. Date of booking <br />v. Date MOUD started: continued or induction? <br />vi. Date of release if applicable <br />vii. Schedule first MOUD appointment upon release <br />viii. Which MOUD provided upon release <br />c. lnformation will be collected via the Managed File Transfer (MFT). lt may be shared with <br />Research Data and Analysis (RDA) for evaluation purposes. <br />5. Contract ManagemenUAccounting. <br />a. Ensure specific tools, such as job descriptions, policies and procedures, and statements of work, <br />are developed, and staff are adequately trained on these tools, to ensure consistent and <br />appropriate practice. <br />b. Attend required monthly meetings with HCA DBHR program administrator to discuss project <br />contract requirements, compliance, problem-solving and attend trainings. Attend additional <br />meetings as required or deemed necessary by the HCA DBHR program administrator. <br />c. Contractor will cooperate with periodic site visits by the HCA DBHR program administrator or <br />designee and make all relevant records and personnel available. <br />d. Submit a monthly report and a data spreadsheet through the Managed File Transfer portal (MFT) <br />as detailed in the deliverables table with the A-19 invoice. <br />FY2024 Gontract Deliverables Table <br />Activitv Description Due Date Payment <br />Monthly <br />progress <br />reports <br />Report must include how funding is <br />being spent, status of hiring staff, status <br />of MOUD purchases and other <br />supplies. Program details and how the <br />standard of care, core components <br />(Section 2) are being met, baniers and <br />successes, technical assistance and <br />training participation, staff changes and <br />additional information as needed. <br />Monthly: <br />Reports due on <br />the 1Oth of every <br />month beginning <br />with August 10, <br />2023. <br />$114,870.00 <br />($9,572.50 x 12) <br />Monthly <br />Data <br />Collection <br />spreadsheet <br />Data spreadsheet filled out completely <br />with section 4.b. above following <br />template provided by HCA and shared <br />via MFT. <br />Monthly: <br />Due on the 1Oth <br />of every month <br />beginning with <br />August 10,2023. <br />$114,870.00 <br />($9,572.50 x 12) <br />Amendment Total $229,740.00 <br />6. Billing and Payment. <br />a. This amendment total is for $229,740.00. <br />b. lnvoice System. The Contractor shall submit invoices using State Form A-19 lnvoice Voucher, or <br />such other form as designated by HCA. Consideration for services rendered shall be payable <br />HCA Contract No. K5885-02 Page 6 of 7