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N.C.Department of Environment, Health,and Natural Resources Page 2 of 4 <br /> Division of General Services <br /> FY 97 - 98 <br /> CONTRACT ADDENDUM <br /> Specialized Services Branch 98 53180 068 <br /> Office, Section, or Branch Contract Number <br /> Child Service <br /> Orange Coordination <br /> Contractor Activity <br /> SECTION B: QUALITY ASSURANCE AND OTHER DELIVERABLES <br /> CONTRACT ADDENDUM <br /> 1. All children enrolled in the Child Service Coordination Program will have demographic information in <br /> their client file. <br /> a. Name <br /> b. Date of Birth <br /> c. Race <br /> d. Medicaid number, if applicable <br /> e. County of residence <br /> f. Address <br /> g. Phone number <br /> h. Primary care physician <br /> 2. All children enrolled will have a completed Identification and Referral Form (DEHNR 3748). <br /> 3. All children enrolled will have a completed and signed Letter of Agreement between the designated <br /> Child Service Coordinator and family. <br /> 4. All children enrolled will have.signed Release(s) of Information as appropriate for exchange of <br /> information between agencies identified on the forms. <br /> 5. All children enrolled will have a completed Child and Family Strengths and Needs Assessment at <br /> specified intervals. <br /> 6. All children enrolled will have a completed Status Report Form (DEHNR 3750) at specified intervals. <br /> 7. All children enrolled will have a care coordination plan for problems identified by,the family and child <br /> Service Coordinator. <br /> 8. All children enrolled will have documentation of a referral for Intermediate Assessments at: <br /> a. 15 - 18 months <br /> b. 30 - 36 months <br /> c. 48 - 54 months <br /> Reviewed by <br /> DEHNR 3300(Revised 2/90) <br /> General Services Division (Review 1/95) - 1,ej66 -9 7 <br /> Initials Date <br />