03/31/1983 Agreement C 47 :l
bite
BRANCH OFFICE CLERK OF THE CIRCUIT COURT BRANCH OFFICE
3117 OVERSEAS HIGHWAY 16TH JUDICIAL CIRCUIT P.O. BOX 379
MARATHON, FLORIDA 33050 MONROE COUNTY PLANTATION KEY, FLORIDA 33070
TEL. (305) 743-9036 500 WHITEHEAD STREET TEL. (305) 852-9253
KEY WEST, FLORIDA33040
RECORDER TEL. (305) 294-4641 COUNTY CLERK
COLLECTOR OF DELINQUENT TAXES COUNTY AUDITOR
MEMORANDUM
To : Louie LaTorre , Social Services Director
From: Ralph W. White , Clerk
Subject : Agree . between County & HRS for Transportation Services
to eligible recipients of the Florida Medicaid Program
Date : April 19 , 1983
Enclosed please find three ( 3 ) copies of the Noninstitutional
Professional and Technical Medicaid Provider Agreement by and
between the County of Monroe , State of Florida , and the State of
Florida Department of HRS for providing transportation services
to eligible recipients of the Florida Medicaid Program which the
Board approved at the March 31 , 1983 meeting .
Please have executed and return two ( 2 ) fully executed copies to
the attention of the undersigned .
Ralph W. White
Clerk
by
Deputy Clerk .
RWW/vp
cc : file
Enclosure
11 STATE OF FLORIDA
DEPARTMENT OF Bob Graham, Governor
Health & Rehabilitative Services
District Eleven _
Medicaid Program Office
401 N.W. Second Avenue
Miami, Florida 33128
May 24 , 1983 _ —� ._,,.,,,
e ; t1
Mr. Timothy S. Esquinaldo, SOCArA 7 riL'
Director �`'"
Monroe County Transportation Program �AY 31 1��3 ® V i
Wing III, Public Service Building 9 1
Key West, Florida 33040 d
.Dear Mr. squinaldo:
This is to confirm the telephone conversation between Pablo
Lopez, Medicaid Program Specialist and Joyce, staff member of the
Monroe County transportation program_' in which it was explained that
there is no need for Monroe County to reapply for a Medicaid Tran-
sportation provider number. Monroe County is already an approved
transportation provider and therefore the current number is valid.
This letter also confirms that effective February 1, 1983 , we
implemented the mutually agreed new rate.
A. In-County travel (not to exceed 75 miles one-way) : Pick-up
charge of $1.00 and 0 .10 per 1/10 mile.
B. Out-of-County travel (minimum of 75 miles one-way) : $75 . 00
for the first client and $25 . 00 per each additional client
one-way.
Joyce also told us that you are getting payments on a timely
basis and in accordance with the new rate. We appreciate your
cooperation in the negotiations that led to the revision of the
old rate.
If you have any questions, please contact 1=r. Pablo Lopez at
(305) 377-5148 .
,/7a't--Xt_z.) 45,72---
Karlene Peyton
District Medicaid
Program Supervisor
KP:rh
cc: Louis La Torre, Executive Director, Monroe
Cnunty Snni a1 Sprvi crams
,0f3ff: : 11 --11 i.r�
�a 1 �— -,
•rr4i�t cn f?f?n r- l- CD - CC' t �� v� .�
TA T E OF FLORIDA ,r;,`'?, `�
5O ) '�'If1 TFIIFIID S . /LTH AND REHABILITATIVE SERVI . ES Q •f"`sr',
N.FY WEST FL 1304'1 r
i ................,.onal Professional and Technical i < E�1
Medicaid Provider Agreement D, ' F:,!
. . •:'„ L'- /
This is to certify that of \\.'.� , 1!�;~
�Tim. 7-Trr0v,(For Slroel AJrirow),/\ `. •
M
on this day of 19 , agrees to participate in the Florida Medicaid Pro-
gram.
1. The provider agrees that services will be provided to recipients of the Florida Medicaid Program
without regard to race, color, religion, national origin, or handicap.
. 2. The provider agrees to keep such records as are necessary to fully disclose the extent of services pro-
vided to individuals receiving assistance under the State Plan and agrees to furnish the State Agency upon
request such information regarding any payments claimed for providing these services. Access to these
pertinent records and facilities by authorized Medicaid Program representatives will be permitted upon a
reasonable request.
3. The provider agrees that claims submitted must be for services rendered to eligible recipients of the
Florida Medicaid Program and that payment by the program for services rendered will be based on the pay-
ment methodology in the applicable Administrative Rule. The Provider also agrees to submit requests for
payment in accordance with program policies.
4. The providers of Independent Lab and X-Ray Services, Home Health Services and Rural Health Clinic
Services agree to furnish the Office of Licensure and Certification a completed copy of Form HCFA-1513
(Ownership and Control Interest Disclosure Statement) in accordance with 42 CFR 455.104.
5. The Department agrees to notify the provider of any major changes in Title XIX or State rules and
regulations relating to Medicaid.
•6. Payment made by the State agency shall constitute full payment for services rendered to recipients
under the Medicaid program except in specific programs when co-insurance is required from the recipient.
7. . The provider and the Department agree to abide by the provisions of the Florida Administrative Rules,
Florida Statutes, policies, procedures, manuals of the Florida Medicaid Program and Federal laws and•
regulations.
8. This agreement may be terminated,upon thirty days written notice by either party.The Department may
terminate this agreement upon five days notice In the event of fraud, abuse, or failure of the provider to com-
ply with any or all of the provisions of this agreement.
9. This agreement becomes effective the date the signature of the authorized agent of the Office of
Medicaid is-affixed.
10. Requests for payment reflecting dates of service no more than ninety (90) days prior to the effective
• date of this agreement will be processed.
Office f Medicaid use onl For P evider of Services by
'/� LI• A !I— /✓/L rF
A o ize e icat igna ure ig . ure o a u o ize'r+ .gen 'rovl.er 2-
. Date e
. Medicaid Program Supervisor C-h R t e n1 lin)
1 itle of Medicaid Agent Title of Authorized Agent I Provider
HRS-ME17orin 3001. Jul 82(Replaces Jul 80 edition which may be used)
(Stock Number: 5751-000.300I-7)