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MOLINA HEALTHCARE OF WASHINGTON, INC. <br />PROVIDER SERVICES AGREEMENT <br />SIGNATURE PAGE <br />In consideration of the promises, covenants, and warranties stated, the Parties agree as set forth in this Agreement. <br />The Authorized Representative acknowledges, warrants, and represents that the Authorized Representative has the <br />authority and authorization to act on behalf of its party. The Authorized Representative further acknowledges <br />he/she received and reviewed this Agreement in its entirety. <br />The parties hereby acknowledge that Health Plan's Provider Manual was made available to Provider for review <br />prior to Provider's decision to enter into this Agreement. Health Plan's Provider Manual is available at the Health <br />Plan's website. <br />The Authorized Representative for each party executes this Agreement with the intent to bind the Parties in <br />accordance with this Agreement. <br />Effective Date of Agreement ("Effective Date"): Upon Health Plan Signature <br />Provider Signature and Information. <br />Provider's Legal Name ("Provider") — as listed on applicable tax form (i.e. W-9): <br />County of Kittitas DBA Kittitas County <br />Name — Printed: <br />Authorized Signature: <br />CA4 Y A,)' 5 <br />Title: LJ (' <br />�" <br />Signature Date: S_ d <br />Telephone Number: <br />Fax Number — Official Correspondence: <br />(509) 962-7527 <br />Mailing Address — Official Correspondence: <br />Payment Address — If different than Mailing Address: <br />205 W 5th Ave Suite 1 <br />Ellensburg, WA 98926 <br />Email Address — Official Correspondence: <br />Tax ID Number — As listed on corresponding tax form: <br />Britta.Cantu.sh@co.kittitas.wa.us co.kittitas.wa.us <br />916001349 <br />NPI — That corresponds to the above Tax ID Number: <br />Specialty: <br />1063226272 <br />Prison Health <br />Health Plan Signature and Information. <br />Molina Healthcare of Washington, Inc., a Washington Corporation ("Health Plan") <br />Name — Printed: <br />Authorized Signature: <br />Emily Leigh <br />Title: VP, Network Mgmt. & Ops <br />Countersignature Date: <br />Mailing Address — Official Correspondence: <br />Email Address — Official Correspondence: <br />Molina Healthcare of Washington, Inc. <br />MHWProviderContracting@MolinaHealthcare.com <br />Attention: President <br />22522 29 h Dr SE Ste 210 & 212 <br />Bothell, WA 98021 <br />MHWPROV22.3 MHWPSA/Revised Jan 2024 Page l of 25 <br />