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Agreement with 0CEH for Dental Services <br /> FY 2012-13 <br /> services on the OCHO Dental C|inicaohadu|e/caendar. <br /> b. Encourage parents to arrive to appointments on-time and require parents to inform <br /> OCHSVEHS and OCHDif cancellation isnecessary, <br /> cJo provide necessary parental permissions, information for the Eligibility Determination <br /> forms, and the Medical and Dental Histories for each child prior to that child undergoing <br /> treatment. C)CHSVEH8 will bring all signed forms prior to the day ofservice. <br /> d.To provide CAP-H.S.S.-30 forms or OCHS/EHS form pertaining to dental health and will <br /> make the completed form a port of the child's permanent OCH8/EHS record. <br /> e. To obtain a copy of each child's Medicaid card or other dental insurance and bring a copy <br /> tp the OCHOon the scheduled day ofservice. <br /> 7. In the event that enrollment in OCHSVEHS program ceases or is significantly reduced during the <br /> term of this agreement, [3CHS/EH@ may terminate this agreement upon 3O days notice and (]CHOwill <br /> return a pro rata share of the payment for services not provided (approximately$100 per enrolled child for <br /> those children whose dental work has not been abarted). <br /> 8.. The parties agree that there shall be no unlawful discrimination bayed upon nooe, cm|or, enmeatry, <br /> national origin, ne|igion, sex, age, disability orveteran status. <br /> � Q. The parties agree to abide by HIPAA regulations in the sharing of protected health <br /> 10. The term of this initial Agreement is for a period of one year commencing on the 9th day of July, <br /> 2012 and terminating on the 8th day of July, 2013. This agreement shall be renewable by written <br /> agreement signed by the official representatives of the parties. Either party may terminate this Agreement <br /> after providing thirty(30)days notice. <br /> 11. The parties agree to the full and complete performance of the mutual covenants contained herein <br /> and that this Agreement constitutes the sole,full and complete agreement by and between the parties; <br /> and no amendments, changes, additions, deletions or modifications to or of this Agreement shall be valid <br /> unless reduced to writing, signed by the parties and attached hereto. <br /> 12. This agreement shall be governed by the laws of the State of North Carolina. <br /> S:\Managers Working Files\Contracts\Dental\FY 11-12 Head Start Dental Contract.doc <br />