Fully executed program agreement

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NAME AND TITLE NAME AND TITLE NAME AND TITLE NAME AND TITLE NAME AND TITLE NAME AND TITLE NAME AND TITLE SSN / TIN SSN I rlN SSN / TIN SSN / TIN SSN / TIN SSN / TIN STREET NAME AND NUMBER, SUITE, ROOM, ETC.CITY STATE ZIP CODE STREET NAME AND NUMBER, SUITE, ROOM, ETC,STATE ZIP CODECITY Business Locations for the disclosed organization, if different from the Primary Business Address STATE ZIP CODEADDRESSCITY PERCENTAGE List each individual who has ownership, controlling interest, is an agent, managing employee, officer, or member of the board of directors of the provider listed in Section I and has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, or Title XVlll, XlX, or XX, since the inception of those programs. Attach additional pages as necessary. Vl. Criminal Offenses (see instructions) ADDRESS STATE ZIP CODECITY PERCENTAGE Does any owner of the provider listed in Section I also have an ownership or controlling interest of 5% or more in any other entity? Attach additional pages as necessary CITY STATE ZIP CODEADDRESS PERCENTAGE CITY ZIP CODEADDRESSSTATE PERCENTAGE List each person with an ownership or controlling interest in any subcontractor in which the provider listed in Section I has direct or indirect ownership of 5% or more. Attach additional pages as necessary. V. Su bcontraetor lnformation (see instructions ) lV. Organizations with Ownership or Management lnterest (continued) DATE OF BIRTH STATE ZIP CODEADDRESSCITY SSN / TIN DATE OF BIRTH Federal statutes and regulations clearly prohibit states from paying for items or services furnished, ordered or prescribed by excluded parties. States are required to search the exclusions databases by the name of a provider entity seeking to participate in the program and also by the name of any owner, managing employee, or controlling interests including officers and members of a board of directors. Have you, any of your managing employees, or any individual who has an ownership or controlling interest of the provider listed in Section I ever been placed on the federalOffice of the lnspector General, Health and Human Services (OIGIHHS) exclusions list or on the System for Award Management (SAM), or othenruise been suspended or debarred from participation in Medicare, Medicaid, orTitleXVlll, XlX, orXXservices programs. lf yes, listeach person below. Attach additional pages as necessary. The lists of excluded individuals can be found at: http.//exclusions.oiq hhs.qov/ and https://www.sam.qov. Vll. Suspension or Debarment (see instructions) CITY STATE ZIP CODEADDRESS PERCENTAGE ADDRESS DSHS 27-094 (REV. 02/2017) CITY STATE ZIP CODE Page 4