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Payment rmation and/or <br />Amount <br />Reimbursement for actual costs, <br />not to exceedtotal funding <br />consideration. Action Plan and <br />Progress Reports must only reflect <br />activities paid for with funds <br />provided in this statementofwork <br />for the specified funding period. <br />See Program Specific <br />Requirements and Special Billing <br />Requirements.Children and Youth with Health Care Needs <br />3a Com Health (cH IF)data into Access 15,2022CHIFAutomated System on all infants and children served <br />bunement for actua <br />by theCYSHCN Program asreferenced in CYSHCN <br />Washington website: <br />https: //secureaccess.wa. eov <br />Aplil'15,2022 <br />IuIy 15,2O22 <br />not to exceed total funding <br />consideration. Action Plan and <br />Progress Reports must only reflect <br />activities paid for with funds <br />provided in this statementofwork <br />for the specified funding period. <br />unmet CYSHCN on and refer co Health 30 daysato DOH CYSHCN Program forapprovalto access <br />Diagnostic and Treatment funds to meet the need. <br />ate <br />Authorization forrns and Central completed <br />Treatment <br />CYSHCN <br />Fund requests directly to the <br />as needed. <br />3c Work with partners to share updated local CYSHCN Review resources foryourlocal area on September30, 2022 See Program Specific <br />Requirements and Special Billingresources with Within Reach/ Help Me Grow ([IMG).ParentHelg l23.ore annually for accuracy <br />and submit to Within Reach. <br />Due Date/Time tr'rame <br />January 15,2022 <br />April 15,2022 <br />JuIy 15,2O22 <br />DraftAugust 19,2022 <br />Final- September 9, <br />2022 <br />Deliverables/Outco mes <br />lubmit quarterly Action Plan reports to <br />DOH Contractmanager <br />Submit MCHBGAction plan to DOH <br />contractmanager <br />Activify <br />Report activities and outcomes of 2022 MCHBG Action <br />Plan using DOH- provided template. <br />Develop 2022-2023 MCHBG Action Plan for Octo b er 1 <br />2 022 through Septemb J 0 2023er usmg DOH -provided <br />template. <br />Task <br /># <br />2a <br />2b <br />DOH Program and tr'iscal contact Information for all concon Sows can be found on the DoH Finance Sharepoint site. euestions related to this sow, or any otherfina nce-related inquiry, may b e sent to fina nce@.doh.wa. gov <br />rqq"rat Ftndtng Att (Applies to federalsubrecipient funding.)This statementofwork is supportedby federalfundsthatrequire comptiancewith the FederalFunaiog el.orrliailrty andrransparencyAct(FFATA or theTransparencyAct).The purpose of the Transparency Act is to make information available online so the public .uo r". no* the federalfunds are spent. <br />To comply with this actand be eligible to perform the activities in this statement of work, the LHJ must have a Data Univen al Numbering System @uNS@) number. <br />InformationabouttheLHJandthisstatementofworkwillbemadeavailableonusASoendine.govbyDoHasrequiredbyp.L. l0g-2g2. <br />Pro gram Specific Requirements <br />Program Manual, Handbootg Policy References: <br />Children and Youth with Special Health Care Needs Manual - <br />Health Services Authorization (HSA) Form <br />http://lvlvw.doh.wa.eov/Portals/l/Documents/pubs/910402-AoprovedHSA.docx <br />Exhibit A, Statement of Work <br />Template Created Septemb er202l <br />Page2 of3 ContractNumberCLH3 1 0 1 5