Agenda - 04-17-1990 - Laserfiche WebLink

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N.C. Department of Environment, Health, and Natural Resources Division of General Services CONTRACT ADDENDUM Children and Youth Section Office, Section, or Branch Orange County Health Dept. Contractor ADMINISTRATIVE SECTION Page 1 of 3 91 --5454 -068 Contract Number Children's Special Health Acriviry Services 1. An estimated 45 (number) new clients will be admitted to this clinic.* 2. An estimated 50 (number) client visits will be made to this clinic. (This is a one -time only clinic) 3. An estimated 50 (number) of CSHS- eligible clients will receive assessments (see HSIS manual for definition). 4. An estimated N/A (number) of CSHS - eligible clients will receive treatment (see HSIS manual for definition). (All patients referred for treatment) 5. An estimated _NJ A (number) of CSHS - eligible clients will receive therapy. (All patients referred for therapy) 6. What counties are served by this clinic? I. Orange 3. 5. 2. 4. 6. 70 List laboratory and diagnostic services funded by this contract. 1. X -rays 3. 5. 2. 4. 6. 8. List other services funded by this clinic, e.g., casting, therapy, etc. 1. N 3. 5. 2. 4. 6. 9. Please attach current eligibility criteria and fee schedule used in this clinic. CSHS criteria 10. Describe on a separate sheet methods for billing for third -party payers, e.g., insurance, Medicaid, etc. Medicaid billing is processed by the HSIS system 11. Who is the clinic coordinator or contact person? Name: __Judy Butler RA. . Phone: Z32 -8181, ext. 305 12. List on a separate sheet subcontractors for services by name, address, and discipline. Dr. Stephen Grubb, 101 Conner Drive, Suite 200, Chapel Hill, NC 27514 *Refer to HSIS Output Reports: Children's Special Health Services for service objectives #1 -4. DEHNR 3340 (Revised 2/90) General Services Division (Review 1/95) Reviewed by �Zl�iy Initials Date