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STATE OF CALIFORNIA

STANDARD AGREEMENT

STD 213 (Rev 06/03)

AGREEMENT NUMBER




«Contract_Number»




REGISTRATION NUMBER







1. This Agreement is entered into between the State Agency and the Contractor named below:




STATE AGENCY'S NAME




California Department of Mental Health AND California Department of Health Care Services




CONTRACTOR'S NAME



«Contractor_Name»

2.

The term of this

April 1, 2012, through December 31, 2012
December 31, 2012

or upon DGS approval, whichever is later






Agreement is:




3. The maximum amount




of this Agreement is:







4. The parties agree to comply with the terms and conditions of the following exhibits which are by this reference made a part of the Agreement.
















Exhibit A – Scope of Work

Pages 3-7




Exhibit A1 – Service Delivery, Administrative and Operational Requirements

Pages 9-66




Exhibit B - Payment Provisions

Pages 67-73




Exhibit C* – General Terms and Conditions

GTC-610




Exhibit D – Special Provisions

Pages 75-79




Exhibit E – Additional Provisions

Pages 81-84




Exhibit F – HIPAA Business Associate Addendum

Pages 85-100





Attachment A – Business Associate Data Security Requirements

Pages 101-105

Items shown with an Asterisk (*), are hereby incorporated by reference and made part of this Agreement as if attached hereto.

These documents can be viewed at www.ols.dgs.ca.gov/Standard+Language

These documents can be viewed at www.ols.dgs.ca.gov/Standard+Language

attached hereto.



These documents can be viewed at www.ols.dgs.ca.gov/Standard+Language


IN WITNESS WHEREOF, this Agreement has been executed by the parties hereto.

CONTRACTOR

California Department of General Services Use Only

CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.)

«Contractor_Name»

BY (Authorized Signature)



DATE SIGNED(Do not type)

PRINTED NAME AND TITLE OF PERSON SIGNING

«First_Name» «Last_Name»«Suffix», «Title»

ADDRESS




«Address»

«City», CA «Zip»



STATE OF CALIFORNIA

AGENCY NAME




See Page 2 for Official Signatures

BY (Authorized Signature)



DATE SIGNED(Do not type)

PRINTED NAME AND TITLE OF PERSON SIGNING

 Exempt per:










ADDRESS




DMH USE ONLY

 State Master  Contractor  Contract Manager  Accounting  State Controller

STANDARD AGREEMENT (STD 213)

Contract #: «Contract_Number»

Page 2


California Department of Mental Health – Contract Number «Contract_Number»

Kathryn Radtkey-Gaither, Chief Deputy Director Date

1600 9th Street, Room 101, Sacramento, CA 95814

California Department of Health Care Services





Jayna Querin, Chief, Contract Management Unit Date

P.O. Box 997413, 1501 Capitol Avenue, Suite 71.5195, MS 1403

Sacramento, CA 95899-7413


Pursuant to the passage of AB 102, the California Department of Mental Health (DMH) will become the Department of State Hospitals on July 1, 2012. Welfare & Institutions Code, Sections 5775-5783 establish managed mental health care plans for the counties of California, administered by DMH. In accordance with the realignment of State Agency responsibility directed in AB 102 this function and many others currently performed by DMH will be transferred to the Department of Health Care Services (DHCS) effective July 1, 2012. This contract is established by DMH, but will be transferred to DHCS in accordance with this process. In order to facilitate a smooth transition, this Agreement is being issued as a three-party Agreement.



TABLE OF CONTENTS

EXHIBIT A 2

6.State and Federal Law Governing this Contract. 5

This Page is Intentionally Blank 7

EXHIBIT A1 8

Service Delivery, Administrative and Operational Requirements 8

Exhibit B 66

Payment Provisions. 66

Special Provisions 74

This Page is Intentionally Blank 79

EXHIBIT e 80


Additional Provisions. 80

EXHIBIT F 84

HIPAA Business Associate Addendum 84



    1. Recitals 85

    2. Definitions 86

    3. Terms of Agreement 87



    4. Obligations of the Department 97

    5. Audits, Inspection and Enforcement 97

    6. Termination 98

    7. Miscellaneous Provisions 99

Attachment A - Business Associate Data Security Requirements…………… 101-105



    1. Personnel Controls 101

    2. Technical Security Controls 101

    3. Audit Controls 104



    4. Business Continuity/Disaster Recovery Controls 104

    5. Paper Document Controls 105


EXHIBIT A

  1. Term of Contract.

April 1, 2012 – December 31, 2012


It is the intent of the parties that this contract remain in effect only until the earlier of the date that DHCS and the MHP execute a successor MHP contract or December 31, 2012, in accordance with paragraph 4.


  1. Scope of Work.




    1. The Contractor agrees to provide to the Department the services described herein: Provide or arrange for the provision of specialty mental health services to Medi-Cal beneficiaries of «County» County within the scope of services defined in this contract.




    1. The services shall be performed at appropriate sites as described in this contract.




    1. The services shall be provided at the times required by this contract.




    1. The project representatives during the term of this agreement will be.


Department
County Technical Assistance:
http://dmh.ca.gov/Services_and_Programs/Community_Programs/County_Technical_Assistance.asp
916-654-2147 (Phone)

916-654-5591 (Fax)


Contractor
«Contractor_Name»

«First_Name» «Last_Name»«Suffix», «Title»

Phone: «Phone»

Fax: «Fax»

Direct all inquiries to:


Department
County Technical Assistance

1600 9th Street, Room 100

Sacramento, CA 95814
Contractor
«Contractor_Name»

«First_Name» «Last_Name»«Suffix», «Title»

«Address»

«City», CA «Zip»


Either party may make changes to the information above by giving written notice to the other party. Said changes shall not require an amendment to this contract.


  1. See Exhibits B, C, D, E, and F which are made part of this contract, for a detailed description of the work to be performed.
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