– do not enter anything in the line. The Beaver County Law office will assign a new resolution number for this amendment.
– Enter the formal corporate name of your agency.
Date of Original Contract
– Enter the date the original contract was signed by the Beaver County Commissioners. This would be the resolution number converted into a date. For example, if the resolution number of your original contract is 071411-43, the date you would enter on this line would be July 14, 2011.
– Enter the fiscal year in the format 2010/11.
Original/Amended Contract Amount
– Enter the TOTAL of the current contract. If this is the first amendment of the fiscal year, enter the total of all of the programs in the contract that you are amending. If the original contract had been amended, enter the total allocation of all of the programs included in the most recent amendment.
– Enter the TOTAL of the increase of all of the programs combined for the contract amendment.
– Add the amount the allocation is to be increased to the former allocation and enter it in this line.
Signature of the Service Provider Executive Director
– the executive director of the corporation is to affix his/her signature on this line and enter the date the document is signed. The amendment submitted to the BCBH Office must have an original signature. Photocopies will not be accepted.
Signature of the Provider Board Chairman
– The Board Chairman of the corporation is to affix his/her signature on the line and enter the date the document was signed. If the board chairman is unable to sign the amendment, a designee can sign the amendment instead; however, the corporate board must pass a resolution stating that this person is designated to sign the amendment and a copy of that resolution must be submitted to the BCBH Office.
Provider NPI Number
– Enter all of the National Provider Index number of the corporation, if applicable. This is a standard identifier for Health Care providers mandated by HIPAA.
Original Contract Amount
– Enter the most recent contract total. If this is the first amendment of the fiscal year, enter the total of all contracted programs covered by the original contract. If the contract was amended, enter the total allocation of the most recent contract amendment.
– Enter the amount of the increase of the contract.
Amended Contract Amount
– Enter the combined total of the most recent approved contract/amendment plus the amount of the allocation adjustment.
Original Contract Resolution Number
– Enter the resolution Number of the original contract for the fiscal year of the contract amendment. This number is found at the top of the front page of the original approved contract.
– Enter the applicable year of the contract amendment in this format: 2010/11
Name of Provider
– Enter the corporate name of you agency.
– Enter the page number and total number of pages of the Exhibit A’s that are being submitted.
Type of Service
– Enter all of the programs in the original or most recent contract amendment, not just the programs that are affected by the contract amendment.
– Enter the contract period for the programs. If the program is in effect for the entire contract year, enter the period in the following format: 7/1/10 to 6/30/11. If a new program was added during the fiscal year, enter the beginning date of the program instead of 7/1. If a program has ended during the fiscal enter the end date of the fiscal year instead of 6/30. If the amendment also includes a change in the rate, all rates during the fiscal year must be listed for the time period they were in effect. For example, if Program A had a rate of $10 per hour for the period July 1 through November 30 and the rate changed to $15 per hour on December 1, you would enter: Program A 7/1/10 to 11/30/10 $10 on one line and: Program A 12/1/10 to 6/30/11 $15 on another line.
–Enter the number of units estimated to be provided during the contract period for the period each rate is in effect.
–Enter the rate for each fee for service program as calculated on the budget form (Exhibit D)
– Enter the contract amount for each program from the most recent approved contract – either the original contract or the most recent subsequent amendment.
– Enter the amount that the budget is changing. This may be an increase or decrease as long as the net result of the changes is an increase.
– combine the amounts in the Previous Budget column and the Budget Change column. If you provide a service that has multiple rate levels, subtotal that program’s budget in the next line. For example:
Prevocational – Base Level $10,000
Prevocational – Level 1 $20,000
Prevocational – Level 2 $30,000
Subtotal- Prevocational $60,000
– Total the budget amounts in the Previous Budgets, Budget Changes and Revised Budget columns in both the Fee-for-Service section and the Program Funded section and enter the total in the sub-total box.
– Enter in these boxes the sum of the subtotals for the Fee-for-Service section and the Program Funded section.
Attach a revised budget form (Exhibit D) for each program that has a change of allocation.
Sometimes because of different hardware and software defaults, Exhibit A will print out on two pages. If this happens with you amendment, delete one of more of the blank lines in order for Exhibit A to fit on one page.