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CITY <br /> Washington State INTERAGENCYAGREEMENT HCA Contract Number: K2850 <br /> Health Care Authority <br /> Ground Emergency Medical <br /> Transport (GEMT) <br /> THIS AGREEMENT made by and between Washington State Health Care Authority, hereinafter referred to <br /> as "HCA," and the party whose name appears below, hereinafter referred to as the "Contractor." <br /> CONTRACTOR NAME CONTRACTOR doing business as(DBA) <br /> CITY OF EVERETT <br /> CONTRACTOR ADDRESS WASHINGTON UNIFORM BUSINESS IDENTIFIER(UBI) <br /> 2930 Wetmore Avenue, Ste 7A <br /> Everett, WA 98201 <br /> CONTRACTOR CONTACT CONTRACTOR CONTRACTOR E-MAIL ADDRESS <br /> TELEPHONE <br /> rvar-ecRcvc rcttwo.qov <br /> HCA PROGRAM HCA DIVISION/SECTION <br /> Ground Emergency Medical Transport FSD <br /> HCA CONTACT NAME AND TITLE HCA CONTACT ADDRESS <br /> Shauna James PO Box 45510 <br /> Medical Assistance Program Specialist 3 Olympia, WA 98504-5510 <br /> HCA CONTACT TELEPHONE HCA CONTACT E-MAIL ADDRESS <br /> (360) 725-1952 HCAGEMTAdminjhca.wa.gov <br /> IS THE CONTRACTOR A SUBRECIPIENT FOR PURPOSES OF CFDA NUMBER(S) FFATA Form <br /> THIS CONTRACT? Required <br /> DYES NO OYES NO <br /> CONTRACT START DATE CONTRACT END DATE <br /> 12/01/2018 06/30/2019 <br /> PURPOSE OF CONTRACT: <br /> To establish an Intergovernmental Transfer framework for HCA to reimburse the Contractor for providing Medicaid <br /> covered ground emergency medical transports pursuant to HB2007. <br /> ATTACHMENTS/EXHIBITS. When the box below is marked with an X, the following Exhibits/Attachments are attached and <br /> are incorporated into this Contract Amendment by reference: <br /> ® Exhibit(s) (specify): Exhibit A, Statement of Work <br /> ❑ Attachment(s) (specify): <br /> ❑ Schedule(s) (specify): <br /> ❑ No Exhibits/Attachment <br /> This terms and conditions of this Contract are an integration and representation of the final, entire and exclusive <br /> understanding between the parties superseding and merging all previous agreements, writings, and <br /> communications, oral or otherwise, regarding the subject matter of this Contract. The parties signing below <br /> warrant that they have read and understand this Contract, and have authority to execute this Contract. This <br /> Contract shall be binding on-HCA only upon signature by HCA. <br /> CONTRACTOR SIGNATURE / PRINTED NAME AND TITLE DATE SIGNED/ ) r,�/ fir- _ <br /> ( /' :i'!�- - '^l��L(o ! I r, Com V-.7/ i' <br /> HCA SIG TURE PRINTED NAME AND TITLE DIE SIGNED <br /> C /�', �J James Gayton, Contracts Administrator ''1 (7.06 <br /> v VUV/// Division of Legal Services / <br /> AP ROVED T ORM AT ► ST; /. <br /> JAMES D.ILES,Ci Attorney . City Clerk <br /> State of Washington Page 1 of 19 Contract No.K2850 <br /> Health Care Authority <br />