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Docusign Envelope lD: 7 4E827 C5-FAB8-8084-827C-414AD59920A6 <br />MOLTNA HEALTHCARE OF WASHINGTON, NC. <br />PROVIDER SERVICES AGREEMENT <br />SIGNATURE PAGE <br />ln consideration of the promises, covenants, and rvarranties stated, the Parties agree as set forth in this Agreen'rent. <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 acknorvledges <br />he/she received and revielved this Agreement in its entilety. <br />The palties heleby acknowledge that Health Plan's Provider Manual r.vas made available to Provider for revie'uv <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 parfy 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 and Information. <br />Health Plan re 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 />CLAY h,.IER'44r' <br />Authorized Signature: <br />ritle: 5hac, [S Signature Date: / g-6- 76 <br />Telephone Number: <br />(s09) 962-7s27 <br />Fax Number - Official Conespondence: <br />Mailing Address - Official Correspondence <br />205 W 5th Ave Suite I <br />Ellensbr.rg, WA 98926 <br />Payment Address - [f different tlian Mailing Address <br />Email Address - Official Correspondence: <br />B ritta.Cantu.sh@co.kittitas.!va.us <br />Tax ID Number - As listed on corresponding tax form <br />916001349 <br />NPI - That corresponds to the above Tax ID Number: <br />t063226272 <br />Specialty: <br />Pr'lson Health <br />Molina Healthcare of Washington, Inc., a Washington Corporation ("Health Plan") <br />Name - Printed: <br />Emily Leigh <br />Authorized Sisnature: <br />-slgned <br />by: <br />€^,h l"rl, <br />Title: VP, Network Mgmt. & Ops coirnteisigniture Date: 5 / 20 / 202b <br />Mailing Address - Official Conespondence: <br />Molina Healthcare of Washington, [nc. <br />Attention: President <br />22522 29th Dr SE Ste 210 & 2t2 <br />Bothell, WA 98021 <br />Email Address - Official Correspondence: <br />MHWPLoviderContracti ng@Mol inaHealthcare.com <br />MHWPROV22,3 MHWPSA./Reviscd Jan 2014 Page I of25