Resolution 081-1983
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RESOLUTION NO. 081 -1983
RESOLUTION AUTHORIZING THE CHAIRMAN OF THE BOARD OF
COUNTY COMMISSIONERS OF MONROE COUNTY, FLORIDA TO
EXECUTE A NONINSTITUTIONAL PROFESSIONAL AND TECHNICAL
MEDICAID PROVIDER AGREEMENT BY AND BETWEEN THE COUNTY
OF MONROE, STATE OF FLORIDA, AND THE STATE OF FLORIDA
DEPARTMENT OF HEALTH AND REHABILITATIVE SERVICES FOR
PROVIDING TRANSPORTATION SERVICES TO ELIGIBLE RECIP-
IENTS OF THE FLORIDA MEDICAID PROGRAM.
BE IT RESOLVED BY THE BOARD OF COUNTY COMMISSIONERS OF MONROE
COUNTY, FLORIDA, as follows:
That the Mayor and Chairman of the Board of County Commissioners
of Monroe County, Florida, is hereby authorized to execute a Non-
institutional Professional and Technical Medicaid Provider Agreement
by and between the County of Monroe, State of Florida, and the State
of Florida Department of Health and Rehabilitative Services, a copy
of same being attached hereto, for providing transportation services
to eligible recipients of the Florida Medicaid Program.
Passed and adopted by the Board of County Commissioners of
Monroe County, Florida, at a regular meeting of said Board held
on the 31st day of March, A.D. 1983.
BOARD OF COUNTY COMMISSIONERS OF
Mq~ROE COUNTY, FLORIDA
~
By
r Chairman
(Seal)
Attest: RALPH W WHITE, CLERK
't. .' I'A. ~ .C-.
Clerk
BY
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'Y F Y ~'[ S T r L
TATE OF FLORIDA
I\L TH AND REHABILITATIVE SERVICES
~.~?~,2.......\,0nal Professional and Technical
Medicaid Provider Agreement
This is to certify that
N'!m~rovTdCr
of
Street Address
, CityiiicfSfat'; ---, '-----~---'-~--_:__--'-- ,
LIp Cc,de
..
on this ___ day of
gram.
19 _, agrees to participate in the Florida Medicaid Pro-
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 ar)d 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 m.;ljor 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 of Medicaid use only
For Provider of Services by
AuthOrized Medicaid Signature
Signature of AuthOrized Agent I Provider
Date
Date
Title of Medicaid Agent
Title of Authorized Agent I Provider
....................................................................
HRS.MED Form 3001, Jul 82 (Replaces Jul 80 edition which may be used)
(Stock Number: 5751.000-3001-7)