DHR Maria Greene, Acting Commissioner

Department of Human Resources  Division of Family and Children Services  Janet R. Oliva, Ph.D., Division Director

Two Peachtree Street, NW  Suite 19-490  Atlanta, Georgia 30303-3142

Phone: 404-651-8409  Fax: 404-657-5105

December 1, 2018

Dear Level of Care Applicant:

Recently the staff of the Department and several providers met to go over the contract recently mailed to you for your signature. The outcomes of that meeting were some immediate changes and a commitment from the Department for a longer term look at the contract language before the renewal process begins for July of this year. Enclosed are the immediate changes the Department agreed to make. The changes affect Paragraph 201, items 2, 6, 18 and 19. These changes are contained on pages 9 and 10 of your contract. I have included five sets of changes for you to insert into your contract before signing and returning them in the self-addressed envelop previously provided to you. After substituting the new pages in all five contracts, please discard the old pages 9 and 10.

Additionally, and in order to expedite this process even more, please be sure:

*your agency fiscal year end, month and day, is noted at the top right of the contract's front page under where the DHR CONTRACT #427-93- appears;

*you return at least one original board resolution, if you have not already done so;

*you return the completed IRS page, including your FEI number;

*your agency's registration is current at the Secretary of State's Office if your agency is a corporation.

It is certain that some crossing in the mail will occur between agencies that have signed contracts and the receipt of these new pages. If you wish to have the pages substituted before DHR signs and returns the contracts to you, please send me a written request to do so. Without the written request to make this change, the contract will remain as signed by you. In the case that you have already received your fully executed contract, I will need a request to make a revision to the executed contract so that the audit paper trail of events remains intact.

I can be reached at 404/657-3304 however Dan Elmore has been engaged to complete this process. He is at the same address in DHR that I am. His telephone number is 404/657-2076.

Sincerely,

Roger L. Smith

Planning and Budget Administrator

Enclosures

Georgia Department of Human Resources

Authorization Agreement for Electronic Payment

(Name of Business or Local Agency)

(Street Address)

(City, State, Zip Code)

(FEI Number)

I authorize the Georgia Department of Human Resources (DHR) to deposit the payment for the above named business or local agency directly into the entity's bank account. DHR is authorized to adjust any over/under deposit which it has caused to be made to this account. I recognize that the deposit of the payment shall be made by electronic means through electronic data interchange (EDl). I further acknowledge that the responsibility of DHR to provide this payment shall be satisfied by DHR providing a correct credit entry in accordance with the automatic deposit services agreement (credits) between DHR and First Union Bank.

The amount of the payment is to be deposited into the checking account of the entity at (name of financial institution). Attached below is a voided check showing the correct information for the account. If our bank or bank account changes or if we decide to stop the electronic payment process, I am responsible for notifying the DHR Office of Financial Services (OFS) in writing of the change immediately.

In signing this authorization for EDI, I understand that certain checks will not be "automatically deposited into the checking account but will be provided to this entity. These checks include:

I) First check after OFS establishes EDI for this entity. (Bank requires pre-notification.)

2) First check after OFS enters authorized changes to the bank account information.

Signature Person Authorized on Bank Account DATE

(print name)

Title of Person Authorized on Bank AccountPhone Number

ATTACH VOIDED CHECK HERE

Send form and voided check to: Georgia Department of Human Resources

Office of Financial Services

Accounts Payable Section

2 Peachtree Street, N. W . Suite 27.402

Atlanta, GA 30303-3142