Agenda - 08-17-2004-5s - Laserfiche WebLink

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4 c. To provide necessary parental permissions, information for the Eligibility Determination forms, and the Medical and Dental Histories for each child prior to that child undergoing treatment. OCHS/EHS will bring all signed forms on the day of service. d. To provide CAP-H.S.S.-30 forms pertaining to dental health and will make the completed form a part of the child's permanent OCHS/EHS record. e. To obtain a copy of each child's Medicaid card or other dental insurance and bring a copy to the OCHD on the scheduled day of service. 9. In the event that enrollment in OCHS/EHS program ceases or is significantly reduced during the term of this agreement, OCHS/EHS may terminate this agreement upon 30 days notice and OCHD will return a pro rata share of the payment for services not provided (approximately $100 per enrolled child for those children whose dental work has not been started). 10. The parties agree that there shall be no unlawful discrimination based upon race, color, ancestry, religion, sex, age, disability or veteran status. 11. The parties agree to abide by HIPAA regulations in the sharing of protected health information. 12. The term of this initial Agreement is for a period of one year commencing on the 1st day of July, 2004 and terminating on the 30th day of June, 2005. This agreement shall be renewable by written agreement signed by the official representatives of the parties. Either party may terminate this Agreement after providing thirty (30) days notice. 13. The parties agree to the full and complete performance of the mutual covenants contained herein and that this Agreement constitutes the sole, full and complete agreement by and between the parties; and no amendments, changes, additions, deletions or modifications to or of this Agreement shall be valid unless reduced to writing, signed by the parties and attached hereto. 14. This agreement shall be governed by the laws of the State of North Carolina.