Liability Waiver Template by wtn20910

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									        CASE MANAGEMENT PROVIDER IDENTIFICATION PAGE


NPI

AGENCY NAME

CITY

REPORT TYPE (ACTUAL/PROJECTED)

FYE




RATE REFLECTED -

W0578   Case Management (MR/DD)                $ 0.00

W0574   Case Management For Children (MR/DD)   $ 0.00

W0579   Case Management (CMI)                  $ 0.00

W0580   Children's Mental Health Waiver        $ 0.00

W1330   Habilitation Services                  $ 0.00   Provider #

W1409   Brain Injury Waiver                    $ 0.00   Provider #

W1410   Elderly Waiver Case Management         $ 0.00
                                                                             Iowa Department of Human Services
                                              FINANCIAL AND STATISTICAL REPORT FOR PURCHASE OF SERVICE CONTRACTS
                                                                                    CERTIFICATION PAGE

AGENCY NAME                                                                                   IRS ID#
ADDRESS                                                                                       PROVIDER NO.                       0
CITY, STATE, ZIP CODE
PERIOD OF REPORT: From                              To                                        DATE OF FISCAL YEAR END                      01/00/00
ADMINISTRATOR NAME                                                                            TELEPHONE NO.
NAME OF PERSON TO CONTACT IF
QUESTIONS ABOUT REPORT                                                                        TELEPHONE NO.

Does agency have an independent audit?                       Yes, for year ending                                                                 No

Has a copy of the latest independent audit been submitted?                          Yes                                                           No

A. Type of Control :                 GOVERNMENT                                     NON-PROFIT ORGANIZATION                                       PROPRIETARY

B. Accounting Basis :                ACCRUAL                                        MODIFIED CASH                                                 CASH

C. Statistical Data For Period of Report :
                                                                                              MEDICAID (TITLE XIX) UNITS
                                                                                                                                                   Elderly            100%
        Service Code                                                       W0578     W0574      W1409        W1330       W0579        W0580        Waiver       MBC   County
     1. Total number of units of service provided


D. Form of Certification by Officer or Administrator of Provider Agency:
   I CERTIFY that I have examined the accompanying schedules of revenues and expenses and the calculations of cost of service
   prepared for this agency and that to the best of my knowledge and belief they are true and correct. I also certify these schedules
   were prepared from the books and records of the facility in accordance with instructions contained in this report, and allowable
   cost of care excludes expenses that were not necessary to provide this care.

                   SIGNED                                                                                (Officer or Administrator of Facility)

                                                   (Title)                                                                      (Date)

E. Statement of Preparer (If Other Than Agency)
   I have prepared this report and to the best of my knowledge and belief, it represents true and accurate data of the agency stated above.

                                                  (Signed)                                                                      (Date)
F. Statement of Project Manager
   I have reviewed this report prior to submitting it to the State (Dept. of Human Services, Bureau of Purchased Services,
   Purchase of Service Unit.)

                                                  (Signed)                                                                      (Date)

SS-1703-0 (Rev. 1/92) 470-0664
AGENCY NAME:                                                                 FYE:                              01/00/00
PROVIDER NO.: 00-00000                                                       REPORT TYPE:                                            0

     SCHEDULE B - STAFF GROSS SALARIES AND STAFF NUMBERS
                                                                       NUMBER OF STAFF
                    JOB CLASSIFICATIONS:                                                                 Gross Salaries and Wages
                                                                 Full Time Part Time         FTE's
                ADMINISTRATIVE - NO. 2110
    Title:




    ADMINISTRATIVE TOTAL - NO. 2110                                   0            0             0.00                                    $0
                  PROFESSIONAL - NO. 2120
    Title:




    PROFESSIONAL TOTAL - NO. 2120                                     0            0             0.00                                    $0
             DIRECT CLIENT CARE - NO. 2130
    Title:




    DIRECT CLIENT CARE TOTAL - NO. 2130                               0            0             0.00                                    $0
                      CLERICAL - NO. 2150
    Title:




    CLERICAL TOTAL - NO. 2150                                         0            0             0.00                                    $0
                    OTHER STAFF - NO. 2190
    Title:




    OTHER STAFF TOTAL - NO. 2190                                      0            0             0.00                                    $0

         TOTAL SALARIES & STAFF NUMBERS                               0            0             0.00                                    $0

The maximum amount of wages chargeable to Purchase of Services for any one employee is $40,000 annually. If an employee is paid in
excess of $40,000, the excess must be reported as "Other Nonreimburseable Costs" in column 3 of Schedule D or charged to Excluded
Services (use separate column on Schedule D). Case management services are exempt from this limitation.

SS-1703-0 (Rev. 1/92) 470-0664
AGENCY NAME:
PROVIDER NO.:     00-00000
FYE:              01/00/00
REPORT TYPE:                  0


         SCHEDULE C - DEPRECIATION AND AMORTIZATION EXPENSE
                                                                        Deprec                                Recorded
                                  Acct. No.    Year       Original                  Deprec    Annual
                                                                       Recorded                              Depreciation
                                   (Sch D)    Acquired     Cost                     Method     Rate
                                                                       Prior Year                              Expense
EQUIPMENT:
BUILDING EQUIPMENT                  4420
  1.                                                                                  SL                               $0
  2.                                                                                  SL                               $0
  3.                                                                                  SL                               $0
  4.                                                                                  SL                               $0
  5.                                                                                  SL                               $0
  6.                                                                                  SL                               $0
  7.                                                                                  SL                               $0
DEPARTMENTAL EQUIPMENT              4420
  1.                                                                                  SL                               $0
  2.                                                                                  SL                               $0
  3.                                                                                  SL                               $0
  4.                                                                                  SL                               $0
  5.                                                                                  SL                               $0
  6.                                                                                  SL                               $0
  7.                                                                                  SL                               $0
OTHER EQUIPMENT                     4420
  1.                                                                                  SL                               $0
  2.                                                                                  SL                               $0
  3.                                                                                  SL                               $0
  4.                                                                                  SL                               $0
  5.                                                                                  SL                               $0
  6.                                                                                  SL                               $0
  7.                                                                                  SL                               $0
OFFICE FURNITURE & FIXTURES         4420
  1.                                                                                  SL                               $0
  2.                                                                                  SL                               $0
  3.                                                                                  SL                               $0
  4.                                                                                  SL                               $0
  5.                                                                                  SL                               $0
  6.                                                                                  SL                               $0
  7.                                                                                  SL                               $0
OTHER                                 4420
  1.                                                                                  SL                               $0
  2.                                                                                  SL                               $0
  3.                                                                                  SL                               $0
  4.                                                                                  SL                               $0
  5.                                                                                  SL                               $0
  6.                                                                                  SL                               $0
  7.                                                                                  SL                               $0
                                                                                             To Sch D line
       SUBTOTAL EQUIPMENT           4420                          $0                             4420
                                                                                                                       $0




                                                   Page 4 of 20
       SCHEDULE C - DEPRECIATION AND AMORTIZATION EXPENSE
                                                                     Deprec                                Recorded
                               Acct. No.    Year       Original                  Deprec    Annual
                                                                    Recorded                              Depreciation
                                (Sch D)    Acquired     Cost                     Method     Rate
                                                                    Prior Year                              Expense
MOTOR VEHICLES:                  4410
  1.                                                                               SL                               $0
  2.                                                                               SL                               $0
  3.                                                                               SL                               $0
  4.                                                                               SL                               $0
  5.                                                                               SL                               $0
  6.                                                                               SL                               $0
                                                                                          To Sch D line
     SUBTOTAL VEHICLES           4410                          $0                             4410
                                                                                                                    $0



                                                                     Deprec                                Recorded
                               Acct. No.    Year       Original                  Deprec    Annual
                                                                    Recorded                              Depreciation
                                (Sch D)    Acquired     Cost                     Method     Rate
                                                                    Prior Year                              Expense

BUILDINGS:
BUILDINGS                        4480
  1.                                                                               SL                               $0
  2.                                                                               SL                               $0
  3.                                                                               SL                               $0
  4.                                                                               SL                               $0
  5.                                                                               SL                               $0
  6.                                                                               SL                               $0
  7.                                                                               SL                               $0
ADDITIONS                        4480
  1.                                                                               SL                               $0
  2.                                                                               SL                               $0
  3.                                                                               SL                               $0
  4.                                                                               SL                               $0
  5.                                                                               SL                               $0
  6.                                                                               SL                               $0
  7.                                                                               SL                               $0
LEASEHOLD IMPROVEMENTS           4480
  1.                                                                               SL                               $0
  2.                                                                               SL                               $0
  3.                                                                               SL                               $0
  4.                                                                               SL                               $0
  5.                                                                               SL                               $0
OTHER                            4480
  1.                                                                               SL                               $0
  2.                                                                               SL                               $0
  3.                                                                               SL                               $0
  4.                                                                               SL                               $0

                                                                                          To Sch D line
TOTAL BUILDINGS & LEASEHOLDS     4480                          $0                             4480
                                                                                                                    $0




                                                                                          To Sch D line
TOTAL EQUIPMENT & BUILDINGS      4400                          $0                             4400
                                                                                                                    $0




                                                Page 5 of 20
            SCHEDULE C - DEPRECIATION AND AMORTIZATION EXPENSE

RELATED PARTY PROPERTY COSTS


1. Is any property being leased from a party "related to provider" using the definitions in the contract and the Provider Handbook?
                                         Yes                                          No

2. SCHEDULE OF LESSOR'S COSTS :
   If answer to number 1 is yes, provide lessor's costs in the space below.
   Depreciation on property
   Property taxes
   Mortgage interest on property
   Insurance
   Other (describe)




   TOTAL                                                                                                         $0




Consultec Schedule C Substituted for          SS-1703-0 (Rev. 1/92) 470-0664




                                                                    Page 6 of 20
AGENCY NAME:                                                                                                                                            FYE: 01/00/00
PROVIDER NO.: 00-00000                                                                                                                          REPORT TYPE: 0
                                                             SCHEDULE D - EXPENSE REPORT
                                                                   TARGETED CASE MANAGEMENT SERVICES
                                                                                           W0578/W0573
                                                                                           W1330/W1409                                W1410                       Indirect
                                            Gross        Revenue     Excluded   Adjusted     MR/DD          W0579        W0580        Elderly          Other      Service
NO.    ACCOUNT TITLE                        Total         Adjust       Costs     Costs      Hab Svc/BI      CMI          CMHW         Waiver         Programs      Costs
2110   Administrative                               $0                                  $0                                                                   $0
2120   Professional Staff - Direct                  $0                                  $0                                                                   $0
2130   Other - Direct                               $0                                  $0                                                                   $0
2150   Clerical                                     $0                                  $0                                                                   $0
2190   Other Staff                                  $0                                  $0                                                                   $0
2100   TOTAL SALARIES                               $0           $0          $0         $0             $0           $0           $0             $0           $0              $0

2210   Health Benefits                              $0                                $0                                                                    $0
2220   Retirement Plan                              $0                                $0                                                                    $0
2290   Other Benefits                               $0                                $0                                                                    $0
2200   TOTAL BENEFITS                               $0         $0         $0          $0             $0             $0           $0             $0          $0               $0

2310   FICA Expense                                 $0                                $0                                                                    $0
2320   Unemployment                                 $0                                $0                                                                    $0
2350   Workmen's Compensation                       $0                                $0                                                                    $0
2300   TOTAL PAYROLL TAXES                          $0         $0         $0          $0             $0             $0           $0             $0          $0               $0

2450   Medical & Psych Services Purchased           $0                                $0                                                                    $0
2470   Accounting and Auditing                      $0                                $0                                                                    $0
2480   Attorney's Fees                              $0                                $0                                                                    $0
2490   Other Non-Medical                            $0                                $0                                                                    $0
2400   TOTAL PROFESSIONAL FEES                      $0         $0         $0          $0             $0             $0           $0             $0          $0               $0

2510   Office Supplies                              $0                                $0                                                                    $0
2530   Medical Supplies                             $0                                $0                                                                    $0
2540   Recreation & Craft Supplies                  $0                                $0                                                                    $0
2550   Food                                         $0                                $0                                                                    $0
2590   Other Supplies                               $0                                $0                                                                    $0
2500   TOTAL SUPPLIES                               $0         $0         $0          $0             $0             $0           $0             $0          $0               $0

2600   TELEPHONE & INTERNET                         $0                                $0                                                                    $0

2700   POSTAGE & SHIPPING                           $0                                $0                                                                    $0               $0

2810   Rent of Space                                $0                                $0                                                                    $0
2820   Building & Grounds Supplies                  $0                                $0                                                                    $0
2830   Utilities                                    $0                                $0                                                                    $0
2840   Care of Buildings & Grounds                  $0                                $0                                                                    $0
2870   Interest Expense                             $0                                $0                                                                    $0
2880   Insurance & Property Taxes                   $0                                $0                                                                    $0
2890   Other Occupancy Expense                      $0                                $0                                                                    $0
2800   TOTAL OCCUPANCY EXPENSE                      $0         $0         $0          $0             $0             $0           $0             $0          $0               $0
                                                            SCHEDULE D - EXPENSE REPORT
                                                                 TARGETED CASE MANAGEMENT SERVICES
                                                                                      W0578/W0573
                                                                                      W1330/W1409                               W1410                     Indirect
                                            Gross        Revenue   Excluded  Adjusted   MR/DD         W0579        W0580        Elderly          Other    Service
NO.    ACCOUNT TITLE                        Total         Adjust     Costs     Costs   Hab Svc/BI     CMI          CMHW         Waiver         Programs    Costs

3100   OUTSIDE PRTG - ART WORK                      $0                            $0                                                                 $0

3210   Mileage & Auto Rental                        $0                            $0                                                                 $0
3250   Agency Vehicles Expense                      $0                            $0                                                                 $0
3280   Automobile Insurance                         $0                            $0                                                                 $0
3290   Other Related Transportation                 $0                            $0                                                                 $0
3200   TOTAL LOCAL TRANS.                           $0        $0        $0        $0            $0            $0           $0             $0         $0              $0

3310   Staff Development & Training                 $0                            $0                                                                 $0
3320   Annual Meetings & Bus. Conference            $0                            $0                                                                 $0
3300   TOTAL CONF. & CONVENTIONS                    $0        $0        $0        $0            $0            $0           $0             $0         $0              $0

3400   SUBSCRIPTIONS/PUBLICS.                       $0                            $0                                                                 $0

3510   Clothing & Personal Needs                    $0                            $0                                                                 $0
3520   Other                                        $0                            $0                                                                 $0
3500   TOTAL ASSISTANCE                             $0        $0        $0        $0            $0            $0           $0             $0         $0              $0

4100   ORGANIZATION DUES                            $0                            $0                                                                 $0

4200   AWARDS & DUES                                $0                            $0                                                                 $0

4310   Agency Vehicle Repair                        $0                            $0                                                                 $0
4320   Other Equipment Repair or Purchase           $0                            $0                                                                 $0
4300   REPAIRS & EXPENDABLE EQUIP.                  $0        $0        $0        $0            $0            $0           $0             $0         $0              $0

4410   Agency Vehicles                              $0                            $0                                                                 $0
4420   Equipment                                    $0                            $0                                                                 $0
4480   Buildings and Leaseholds                     $0                            $0                                                                 $0
4400   TOTAL DEPRECIATION                           $0        $0        $0        $0            $0            $0           $0             $0         $0              $0

4910   Moving & Recruitment                         $0                            $0                                                                 $0
4920   Liability Insurance                          $0                            $0                                                                 $0
4930   Miscellaneous                                $0                            $0                                                                 $0
4900   TOTAL MISCELLANEOUS                          $0        $0        $0        $0            $0            $0           $0             $0         $0              $0

5000   INDIRECT SERVICE COST                        $0                            $0                                                                 $0              $0

       TOTAL EXPENSES                        $0         $0              $0        $0            $0          $0           $0             $0           $0              $0
                ALLOCATION OF INDIRECT PROGRAM SERVICE COSTS                                    $0          $0           $0             $0           $0
                TOTAL SERVICE COSTS AFTER INDIRECT COST                                         $0          $0           $0             $0
                      UNITS OF SERVICE                                                            0           0            0              0
                      UNIT COST                                                              $ 0.00      $ 0.00       $ 0.00         $ 0.00
Provider Agency:
Report Type                            0
Period of Report:         01/00/00           to        01/00/00

                          SCHEDULE E - COMPARATIVE BALANCE SHEET

ASSETS, LIABILITIES AND EQUITY
                                                                                  Balance At End Of
                                                                          Current Period      Prior Period

ASSETS:
           Cash                                                   $
           Receivable from Clients
           Receivable from Others
           Property and Equipment:
              Land
              Buildings and Equipment
                     Less Allowance for Depreciation
              Net Property and Equipment                                           $0.00               $0.00
           Investments and Other Assets
                                                                                   $0.00               $0.00
                    TOTAL ASSETS                                  $

LIABILITIES AND EQUITY:
         Accounts Payable                                         $
         Accrued Taxes (Payroll and Property)
         Other Liabilities


           Notes and Mortgages
                    TOTAL LIABILITIES

           Equity or Fund Balance

                                                                                   $0.00               $0.00
                    TOTAL LIABILITIES AND EQUITY                  $




RECONCILIATION OF EQUITY OR FUND BALANCE

TOTAL EQUITY OR FUND BALANCE BEGINNING OF PERIOD                      $

Add:
           TOTAL REVENUE from Schedule A
           Other Revenue. Explain.


Deduct:
           TOTAL EXPENSES from Schedule D
           Other Expenses. Explain.


TOTAL EQUITY OR FUND BALANCE END OF PERIOD                        $                $0.00               $0.00
Provider Agency:
Report Type:                     0
Period of Report:         01/00/00 to     01/00/00



                                 SCHEDULE F - COST ALLOCATION PROCEDURES
                                 (To be completed by Providers which offer more than one service)


Cost are allocable to a particular service, such as a grant, project, or other activity, in accordance with the relative
benefits received. A cost is allocable to a service if it is treated consistently with other costs incurred for the
purpose in like circumstances, and if it (1) is incurred specifically for the service, (2) benefits the service and can be
distributed in reasonable proportion to the benefits received and (3) is necessary to the overall operation of the
organization, although a direct relationship to a particular service cannot be shown.


Any cost allocable to a particular service under the above principles may not be shifted to other services to overcome
funding deficiencies, or to avoid other restrictions imposed by law or terms of an award.

Direct Costs:                                                                              YES            NO
     1. Do you have a cost allocation plan which describes the methods you
        use in distributing joint costs to services or activities?

      2. If you do not have a cost allocation plan describing the methods
         followed, do you have accounting workpapers available to support
         joint direct cost allocations?

      3. Is your method of allocating joint service costs consistently
         followed from year to year?

      4. Are costs allocated to services in reasonable proportion to benefits
         received?

      5. Are service income deductions allocated in a manner which is consistent
         with the costs incurred in generating the income?

      6. Additional comments regarding allocation of joint service costs:




Indirect Costs:
     1. Are the indirect costs distributed on a basis of total direct service
        or costs?

      2. If indirect costs are not allocated on the basis of total direct service
         costs, what was the basis used?




      3. Is the basis for distributing indirect cost the same as that used in the
         previous year?

SS-1703-0 (Rev. 1/92) 470-0664
                                                Case Management Cost Analysis
AGENCY NAME:
PROVIDER NO.:                        00-00000
FYE:                                 01/00/00
REPORT TYPE:                             0

                                      W0578, W0574. W1330 W1409                                                   W0579 CMI
NO.         ACCOUNT TITLE            01/00/00 12/31/98 % Change   NO.         ACCOUNT TITLE            01/00/00    12/31/98 % Change
2100   Total Salaries                      $0             0.00%   2100   Total Salaries                      $0              0.00%
2200   Total Benefits                      $0             0.00%   2200   Total Benefits                      $0              0.00%
2300   Total Payroll Taxes                 $0             0.00%   2300   Total Payroll Taxes                 $0              0.00%
2400   Total Professional Fees             $0             0.00%   2400   Total Professional Fees             $0              0.00%
2500   Total Supplies                      $0             0.00%   2500   Total Supplies                      $0              0.00%
2600   Telephone & Internet                $0             0.00%   2600   Telephone & Internet                $0              0.00%
2700   Postage & Shipping                  $0             0.00%   2700   Postage & Shipping                  $0              0.00%
2800   Total Occupancy Expense             $0             0.00%   2800   Total Occupancy Expense             $0              0.00%
3100   Outside Prtg - Art Work             $0             0.00%   3100   Outside Prtg - Art Work             $0              0.00%
3200   Total Local Trans.                  $0             0.00%   3200   Total Local Trans.                  $0              0.00%
3300   Total Conf. & Conventions           $0             0.00%   3300   Total Conf. & Conventions           $0              0.00%
3400   Subscriptions/Publics.              $0             0.00%   3400   Subscriptions/Publics.              $0              0.00%
3500   Total Assistance                    $0             0.00%   3500   Total Assistance                    $0              0.00%
4100   Organization Dues                   $0             0.00%   4100   Organization Dues                   $0              0.00%
4200   Awards & Dues                       $0             0.00%   4200   Awards & Dues                       $0              0.00%
4300   Repairs & Expendable Equip.         $0             0.00%   4300   Repairs & Expendable Equip.         $0              0.00%
4400   Total Depreciation                  $0             0.00%   4400   Total Depreciation                  $0              0.00%
4900   Total Miscellaneous                 $0             0.00%   4900   Total Miscellaneous                 $0              0.00%
5000   Indirect Service Costs              $0             0.00%   5000   Indirect Service Costs              $0              0.00%
       Total Expenses                      $0       $0    0.00%          Total Expenses                      $0          $0  0.00%
       Units of Service                     0             0.00%          Units of Service                     0              0.00%
       Unit Cost                        $0.00    $0.00    0.00%          Unit Cost                        $0.00       $0.00  0.00%
                                                 Case Management Cost Analysis

                                                W0580 CMI
NO.         ACCOUNT TITLE            01/00/00    12/31/98 % Change
2100   Total Salaries                      $0              0.00%
2200   Total Benefits                      $0              0.00%
2300   Total Payroll Taxes                 $0              0.00%
2400   Total Professional Fees             $0              0.00%
2500   Total Supplies                      $0              0.00%
2600   Telephone & Internet                $0              0.00%
2700   Postage & Shipping                  $0              0.00%
2800   Total Occupancy Expense             $0              0.00%
3100   Outside Prtg - Art Work             $0              0.00%
3200   Total Local Trans.                  $0              0.00%
3300   Total Conf. & Conventions           $0              0.00%
3400   Subscriptions/Publics.              $0              0.00%
3500   Total Assistance                    $0              0.00%
4100   Organization Dues                   $0              0.00%
4200   Awards & Dues                       $0              0.00%
4300   Repairs & Expendable Equip.         $0              0.00%
4400   Total Depreciation                  $0              0.00%
4900   Total Miscellaneous                 $0              0.00%
5000   Indirect Service Costs              $0              0.00%
       Total Expenses                      $0          $0  0.00%
       Units of Service                     0              0.00%
       Unit Cost                        $0.00       $0.00  0.00%
Provider # NPI                                             Provider Name
0070557   1649482977-251B00000X-508491003   Adair County Case Management
0061929   1528270600-251B00000X-508410000   Adams Union Taylor County Case Mgt
0082974   1730231937-171M00000X-521720000   Allamakee-Howard Co Case Mgmt
0160325   1629147087-104100000X-506770000   Bremer County Case Management
0082487   1306921333-251B00000X-506440000   Buchanan County Case Management
0062331   1255399986-251B00000X-505880000   Buena Vista County Case Management
0092601   1073660163-251B00000X-514010000   Carroll County Case Management
0064873   1437341724-251B00000X-500220000   Cass County Case Mgmt
0082446   0082446                           Cedar Co Case Management
0054726   1467657221-251B00000X-504010000   Cerro Gordo Co Case Mgmt
0136887   1891848693-171M00000X-510120000   Cherokee County Case Mgmt Agency
0062976   1003967365-171M00000X-506590000   Chickasaw-Mitchell County Case Management
0082966   0082966                           Clay County Case Management
0081968   1669640561-251B00000X-527330000   Clinton County Case Management
0150565   1003931866-251B00000X-504410000   Community Services Of Franklin Co
0490656   1144256272-171M00000X-500360000   County Community Services
0492959   1629161898-251B00000X-500030000   Dallas County Community Services
0184457   1366529109-251B00000X-501440000   Decatur County Community Services
0761379   1215072723-251S00000X-520570000   Delaware County Targeted Case Management
0058644   1083707939-251B00000X-526010000   Des Moines County Case Management
0054007   0054007                           DHS Bureau Of Case Management
0085324   1205912094-251B00000X-513600000   Dickinson County Case Management
0422998   1215934955-313M00000X-520010000   Dubuque County Board Of Supervisors
0063032   1215090451-251B00000X-513340000   Emmet County Case Mgmt
0079178   1972727592-251B00000X-521750000   Fayette County Case Management
0083725   1821148875-251B00000X-506160000   Floyd County Case Management
0190793   1265582589-171M00000X-516520000   Fremont County Community Services
0108597   0108597                           Grundy Co Case Management
0082495   1609918036-251S00000X-505950000   Hamilton County Case Management
0063198   0063198                           Hardin County Case Management
0068437   1184780082-251B00000X-526410000   Henry County Comm Serv
0111658   1508048992-251S00000X-521360000   Howard County Case Management
0055228   1992831986-171M00000X-505290000   Humboldt County Case Management
0121772   1144307059-251B00000X-520600000   Jackson Co Case Management
0054395   1558582684-251B00000X-522455941   Johnson County MH/DD Services
0064915   1225167422-171M00000X-522050000   Jones County Case Mgmt
0149161   1407972722-251B00000X-505110000   Kossuth County Case Management
0054015   1831278639-251B00000X-524010000   Linn County MHDD Services
0071654   1457403701-251B00000X-526530000   Louisa County Community Services
0100347   1669552311-171M00000X-525770000   Mahaska County Case Management
0054866   0054866                           Muscatine County Comm Serv
0063073   1871650887-251B00000X-527610000   O'Brein Co General Relief
0089623   1275728966-251B00000X-512450000   Osceola County Case Management
0082511   1134326234-251B00000X-521490000   Polk County Case Management
0082503   1245364082-251B00000X-503090000   Pottawattamie County Case Management
0235564   1427129220-251B00000X-515030000   Poweshiek County Case Management
0175232   1609906510-251B00000X-501120000   Rolling Prairie Case Management
0173336   1154469385-251B00000X-515660000   Sac & Ida Co Case Management
0063107   1750427860-251B00000X-505830000   Scott County Case Mgmt
0063115   1346390812-251B00000X-528010000   Shelby County Case Mgmt
0064519   1568590065-251b00000x-515370000   Southeast Iowa Case Management
0153502   1235286345-251B00000X-525310000   Southwest Iowa Case Management
0063123   1295886232-251B00000X-516320000   Story County Case Management
0069815   0069815                           Tama County Case Management
0173062   1528116209-251B00000X-523420000   Tama/Poweshiek Co Case Management
0208942   1558432401-251B00000X-505010000   Webster County Case Management
0082461   1770655128-251B00000X-504360000   WHW County Social Services
0056390   1710024542-251B00000X-511010000   Woodbury County Case Mgmt
0175240   1073666806-251B00000X-511010000   Woodbury County Case Mgmt
0100735   0100735                           Wright County Case Management
    City         BI #
  Greenfield    0400814
   Corning      0194043
   Waukon       0288522
   Waverly      0735837
Independence    0183186
 Storm Lake
    Carroll     0203430
   Atlantic
    Tipton
 Mason City     0281956
  Cherokee      0791004
New Hampton     0440461
   Spencer      0734681
    Clinton     0181768
   Hampton      0236075
    Boone       0490664
     Adel       0492975
     Leon       0223255
 Manchester     0786079
  Burlington    0255034
 Des Moines     8054007
 Spirit Lake    0457879
   Dubuque
  Estherville   0441006
 West Union
 Charles City   0262899
    Sidney      0189654
Grundy Center   0264887
Webster City    0171181
    Eldora      0401694
 Mt. Pleasant   0259614
    Cresco      0288829
 Dakota City    0267351
 Maquoketa      0206219
  Iowa City     0166686
  Anamosa
    Algona      0160192
Cedar Rapids    0095224
   Wapello
  Oskaloosa     0237487
  Muscatine     0147462
   Primghar     0179952
    Sibley
 Des Moines
Council Bluffs
   Grinnell
 Glenwood        0256834
   Sac City
 Davenport       0741488
    Harlan
 Washington      0203061
  Clarinda       0166538
   Nevada        0162321
    Toledo       0161554
    Toledo       0147462
  Ft. Dodge      0216861
 Forest City     0257071
 Sioux City      0487165
 Sioux City
   Clarion       0152041
Provider # NPI                                             Provider Name
0070557   1649482977-251B00000X-508491003   Adair County Case Management
0061929   1528270600-251B00000X-508410000   Adams Union Taylor County Case Mgt
0082974   1730231937-171M00000X-521720000   Allamakee-Howard Co Case Mgmt
0160325   1629147087-104100000X-506770000   Bremer County Case Management
0082487   1306921333-251B00000X-506440000   Buchanan County Case Management
0062331   1255399986-251B00000X-505880000   Buena Vista County Case Management
0092601   1073660163-251B00000X-514010000   Carroll County Case Management
0064873   1437341724-251B00000X-500220000   Cass County Case Mgmt
0082446   0082446                           Cedar Co Case Management
0054726   1467657221-251B00000X-504010000   Cerro Gordo Co Case Mgmt
0136887   1891848693-171M00000X-510120000   Cherokee County Case Mgmt Agency
0062976   1003967365-171M00000X-506590000   Chickasaw-Mitchell County Case Management
0082966   0082966                           Clay County Case Management
0081968   1669640561-251B00000X-527330000   Clinton County Case Management
0150565   1003931866-251B00000X-504410000   Community Services Of Franklin Co
0490656   1144256272-171M00000X-500360000   County Community Services
0492959   1629161898-251B00000X-500030000   Dallas County Community Services
0184457   1366529109-251B00000X-501440000   Decatur County Community Services
0761379   1215072723-251S00000X-520570000   Delaware County Targeted Case Management
0058644   1083707939-251B00000X-526010000   Des Moines County Case Management
0054007   0054007                           DHS Bureau Of Case Management
0085324   1205912094-251B00000X-513600000   Dickinson County Case Management
0422998   1215934955-313M00000X-520010000   Dubuque County Board Of Supervisors
0063032   1215090451-251B00000X-513340000   Emmet County Case Mgmt
0079178   1972727592-251B00000X-521750000   Fayette County Case Management
0083725   1821148875-251B00000X-506160000   Floyd County Case Management
0190793   1265582589-171M00000X-516520000   Fremont County Community Services
0108597   0108597                           Grundy Co Case Management
0082495   1609918036-251S00000X-505950000   Hamilton County Case Management
0063198   0063198                           Hardin County Case Management
0068437   1184780082-251B00000X-526410000   Henry County Comm Serv
0111658   1508048992-251S00000X-521360000   Howard County Case Management
0055228   1992831986-171M00000X-505290000   Humboldt County Case Management
0121772   1144307059-251B00000X-520600000   Jackson Co Case Management
0054395   1558582684-251B00000X-522455941   Johnson County MH/DD Services
0064915   1225167422-171M00000X-522050000   Jones County Case Mgmt
0149161   1407972722-251B00000X-505110000   Kossuth County Case Management
0054015   1831278639-251B00000X-524010000   Linn County MHDD Services
0071654   1457403701-251B00000X-526530000   Louisa County Community Services
0100347   1669552311-171M00000X-525770000   Mahaska County Case Management
0054866   0054866                           Muscatine County Comm Serv
0063073   1871650887-251B00000X-527610000   O'Brien Co General Relief
0089623   1275728966-251B00000X-512450000   Osceola County Case Management
0082511   1134326234-251B00000X-521490000   Polk County Case Management
0082503   1245364082-251B00000X-503090000   Pottawattamie County Case Management
0235564   1427129220-251B00000X-515030000   Poweshiek County Case Management
0175232   1609906510-251B00000X-501120000   Rolling Prairie Case Management
0173336   1154469385-251B00000X-515660000   Sac & Ida Co Case Management
0063107   1750427860-251B00000X-505830000   Scott County Case Mgmt
0063115   1346390812-251B00000X-528010000   Shelby County Case Mgmt
0064519   1568590065-251b00000x-515370000   Southeast Iowa Case Management
0153502   1235286345-251B00000X-525310000   Southwest Iowa Case Management
0063123   1295886232-251B00000X-516320000   Story County Case Management
0069815   0069815                           Tama County Case Management
0173062   1528116209-251B00000X-523420000   Tama/Poweshiek Co Case Management
0208942   1558432401-251B00000X-505010000   Webster County Case Management
0082461   1770655128-251B00000X-504360000   WHW County Social Services
0056390   1710024542-251B00000X-511010000   Woodbury County Case Mgmt
0175240   1073666806-251B00000X-511010000   Woodbury County Case Mgmt
0100735   0100735                           Wright County Case Management
    City         Hab #
  Greenfield    0793844
   Corning      0791418
   Waukon       0744938
   Waverly      0738591
Independence    0201035
 Storm Lake     0747014
    Carroll     0745075
   Atlantic     0700587
    Tipton
 Mason City     0741231
  Cherokee      0746727
New Hampton     0744540
   Spencer      1734681
   Clinton      0742965
   Hampton      0799502
    Boone       0746586
     Adel       0746214
     Leon       0738831
 Manchester     0769372
  Burlington    0745984
 Des Moines     0743096
 Spirit Lake    0746925
   Dubuque
  Estherville   0742122
 West Union     0763359
 Charles City   0741835
    Sidney      0743104
Grundy Center   0746966
Webster City    0738815
    Eldora      0763458
 Mt. Pleasant   0741884
                0400678
Dakota City     0765305
 Maquoketa      0742114
 Iowa City      0761916
 Anamosa        0794974
  Algona        0401362
Cedar Rapids    0739433
  Wapello
 Oskaloosa      0763243
 Muscatine
 Primghar       0748046
   Sibley       0764324
 Des Moines
Council Bluffs   0763185
   Grinnell      0746594
 Glenwood
   Sac City      0765198
 Davenport       0760132
    Harlan       0795922
 Washington      0748657
  Clarinda       0741827
   Nevada        0746545
    Toledo       0742981
    Toledo
  Ft. Dodge      0738807
 Forest City     0701062
 Sioux City      0762815
 Sioux City
   Clarion

								
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