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DocuSign Envelope ID: 78CDD188-656B-44E9-9F46-9AFBF222884F <br />Washington State , .. -~ <br />HCA Contract Number: K1407 Health care I \uthority CONTRACT Amendment Number: 1 <br />THIS AGREEMENT made by and between Washington State Health Care Authority , hereinafter referred to <br />as "HCA," and the party whose name appears below, hereinafter referred to as the "Contractor." <br />CONTRACTOR NAME CONTRACTOR doing business as (DBA) <br />Kittitas County Health Dept <br />CONTRACTOR ADDRESS WASHINGTON UNIFORM <br />BUSINESS IDENTIFIER (UBI) <br />507 N Nanum Street, Suite 102 <br />Ellensburg, WA 98926 <br />CONTRACTOR CONTACT CONTRACTOR CONTRACTOR E-MAIL ADDRESS <br />TELEPHONE <br />Liz Whitaker (509) 962-7068 liz .whitak er@co.ki tti tas.wa.us <br />HCA PROGRAM HCA DIVISION/SECTION <br />Medicaid Administrative Claiming (MAC) HCS <br />HCA CONTACT NAME AND TITLE HCA CONTACT ADDRESS <br />Jennifer In man PO Box 45506d <br />Olympia , WA 98504 <br />HCA CONTACT TELEPHONE HCA CONTACT E-MAIL ADDRESS <br />(360) 725-1738 iennifer.inman@hc8.wa.Qov <br />IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF CFDA NUMBER(S) FFATA Form <br />THIS CONTRACT? 93.778 Required <br />[81YES O NO DYES [giNO <br />CONTRACT START DATE CONTRACT END DATE TOTAL MAXIMUM CONTRACT <br />AMOUNT <br />01/01/2017 12/31/2018 Nomax <br />PURPOSE OF CONTRACT : <br />The purpose of this Contract is to support Medicaid related outreach and linkage activities performed by Local Health <br />Jurisdictions (LHJ) to Washington State residents who live within its jurisdiction. <br />ATTACHMENTS/EXHIBITS. When the box below is marked with an X, the following Exhibits/Attachments are attached and <br />are incorporated into this Contract Amendment by reference : o Exhibit(s) (specify): <br />~ Attachment(s) (specify): Attachment 2 -MAC Coordinator Manual (Incorporated by reference) <br />~ Schedule(s) (specify): Schedule A -Statement of Work o No Exhibits/Attachment <br />The terms and conditions of this Contract are an integration and representation of the final , entire and exclusive <br />understanding between the parties superseding and merging all previous agreements , writings , and <br />communications, oral or otherwise, regarding the subject matter of this Contract. The parties Signing below <br />warrant that they have read and understand this Contract, and have authority to execute this Contract. This <br />Contract shall be binding on HCA only upon signature by HCA. <br />CONTRACTOR SIGNATURE <br />~ 1f1/ttd&kv <br />1r:~rNAT~~~ ~ /Wt. ~/~ 'L ~ -, ,,-~ <br />State of Washington <br />Health Care Authority <br />~7fv <br />PRINTED NAME AND TITLE DATE SIGNED <br />Liz Whitaker 12/2.7/2£>/'& <br />PRINTED NAME AND TITLE DATE SIGNED <br />Annette Schuffenhauer, Chief Legal Officer Illeh., Division of Legal Services , , <br />Page 1 of 42 HCA Contract No. K1407-1