STATE OF CALIFORNIA
STANDARD AGREEMENT
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STD 213 (Rev 06/03)
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AGREEMENT NUMBER
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«Contract_Number»
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REGISTRATION NUMBER
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1. This Agreement is entered into between the State Agency and the Contractor named below:
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STATE AGENCY'S NAME
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California Department of Mental Health AND California Department of Health Care Services
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CONTRACTOR'S NAME
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«Contractor_Name»
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2.
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The term of this
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April 1, 2012, through December 31, 2012
December 31, 2012
or upon DGS approval, whichever is later
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Agreement is:
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3. The maximum amount
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of this Agreement is:
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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.
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Exhibit A – Scope of Work
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Pages 3-7
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Exhibit A1 – Service Delivery, Administrative and Operational Requirements
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Pages 9-66
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Exhibit B - Payment Provisions
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Pages 67-73
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Exhibit C* – General Terms and Conditions
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GTC-610
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Exhibit D – Special Provisions
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Pages 75-79
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Exhibit E – Additional Provisions
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Pages 81-84
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Exhibit F – HIPAA Business Associate Addendum
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Pages 85-100
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Attachment A – Business Associate Data Security Requirements
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Pages 101-105
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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
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IN WITNESS WHEREOF, this Agreement has been executed by the parties hereto.
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CONTRACTOR
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California Department of General Services Use Only
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CONTRACTOR’S NAME (if other than an individual, state whether a corporation, partnership, etc.)
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«Contractor_Name»
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BY (Authorized Signature)
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DATE SIGNED(Do not type)
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PRINTED NAME AND TITLE OF PERSON SIGNING
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«First_Name» «Last_Name»«Suffix», «Title»
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ADDRESS
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«Address»
«City», CA «Zip»
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STATE OF CALIFORNIA
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AGENCY NAME
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See Page 2 for Official Signatures
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BY (Authorized Signature)
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DATE SIGNED(Do not type)
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PRINTED NAME AND TITLE OF PERSON SIGNING
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Exempt per:
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ADDRESS
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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
EXHIBIT A
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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.
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Scope of Work.
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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.
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The services shall be performed at appropriate sites as described in this contract.
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The services shall be provided at the times required by this contract.
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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.
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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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