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Faith Based Grants for Medical Assistance - Excel

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					                                           TABLE 2: RWSD SUBCONTRACTOR DATA SHEET, REVIEW CERTIFICATION AND SERVICES ALLOCATIONS

                  Administrative Agency:

                       Funding Stream:                                                        Fiscal Year :                                                           Submission Date:
                            Subcontractor:                                                                                                                            Subcontractor 9 digit EIN:
                                               Faith Based Organization?                                      Minority Organization?                                  Selection Process
                                               Minority Provider?                                             HUB Certified?                                          Renewal Year
                          Mailing Address:

            Street Address (if different):
                           City, State, Zip:
                           Phone Number:                                                              Fax:                                          Email Address:
                      Executive Director:
                 Contact Person and Title:

                                               If this agency provides Outpatient/Ambulatory Medical Care, does the agency collect sliding scale fees from clients?
                                               If this agency provides Outpatient/Ambulatory Medical Care, does the agency collect co-payments from Clients?
                                                                                              ESTIMATED OBJECTIVES
                                                                                                                                                                          SUBCONTRACTOR                  TOTAL
                                                                                                                                            SUBCONTRACTOR
                            SERVICE CATEGORY                                                                                                                              ADMINISTRATION           SUBCONTRACTOR COST
                                                                                          Units                         Persons          DIRECT SERVICES COST
                                                                                                                                                                              COSTS                    FOR SERVICE

Outpatient/Ambulatory Medical Care
                                                                                                                                                                                                   $              -
AIDS Pharmaceutical Assistance (local)
                                                                                                                                                                                                   $              -
Oral Health Care
                                                                                                                                                                                                   $              -
Early Intervention Services (Parts A and B)
                                                                                                                                                                                                   $              -
Health Insurance Premium and Cost Sharing Assistance
                                                                                                                                                                                                   $              -
Home Health Care
                                                                                                                                                                                                   $              -
Medical Nutrition Therapy
                                                                                                                                                                                                   $              -
Hospice Services
                                                                                                                                                                                                   $              -
Home and Community-Based Health Services
                                                                                                                                                                                                   $              -
Mental Health Services
                                                                                                                                                                                                   $              -
Substance Abuse Services - Outpatient
                                                                                                                                                                                                   $              -
Medical Case Management (including Treatment Adherence)
                                                                                                                                                                                                   $              -
Case Management (non-medical)
                                                                                                                                                                                                   $              -
Child Care Services
                                                                                                                                                                                                   $              -
Emergency Financial Assistance
                                                                                                                                                                                                   $              -
Food Bank/Home-Delivered Meals
                                                                                                                                                                                                   $              -
Health Education/Risk Reduction
                                                                                                                                                                                                   $              -
Housing Services
                                                                                                                                                                                                   $              -
Legal Services
                                                                                                                                                                                                   $              -
Linguistic Services
                                                                                                                                                                                                   $              -
Medical Transportation Services
                                                                                                                                                                                                   $              -
Outreach Services
                                                                                                                                                                                                   $              -
Psychosocial Support Services
                                                                                                                                                                                                   $              -
Referral for Health Care/Supportive Services
                                                                                                                                                                                                   $              -
Rehabilitation Services
                                                                                                                                                                                                   $              -
Respite Care
                                                                                                                                                                                                   $              -
Treatment Adherence Counseling (non-medical)
                                                                                                                                                                                                   $              -

                                                                    Sub Total                                                            $                     -      $                     -      $              -
                                                                            The following services may not be funded with Ryan White Part B funds
Buddy/Companion Services
                                                                                                                                                                                                   $              -
Child Welfare Services
                                                                                                                                                                                                   $              -
Client Advocacy
                                                                                                                                                                                                   $              -
Transportation
                                                                                                                                                                                                   $              -
Pediatric Developmental Assessment/Early Intervention Services
                                                                                                                                                                                                   $              -
Permanency Planning
                                                                                                                                                                                                   $              -
Referrals to Clinical Research
                                                                                                                                                                                                   $              -
Other Services
                                                                                                                                                                                                   $              -

                                                             Total Allocation                                                            $                     -      $                     -      $              -




DSHS Table 2                                                                                                                                                                                                    Revised 7-14-08
Program Review:
I certify that the purpose and scope of the contract has been reviewed and found to be in compliance with any existing policies of the Division of HIV Services, HIV/AIDS Bureau (HAB) in effect at the time this
contract was executed.


Administrative Fiscal Review:
I certify that the procedures used to advertise and award these funds meet the minimum standards required by the Office of Management and Budget (OMB) in the following Circular (check one only):

          A-102 (Administrative requirements applicable to grants to State and local governments) codified by DHHS in 45 CFR Part 92


          A-110 (Administrative requirements applicable to grants to institutions of Higher Education, Hospitals, and Other Non-Profit Organizations) codified by DHHS in 45 CFR Part 74



I certify that the costs have been determined allowable according to priniciples and standards established by OMB in the following Circular (check one only):


          A-122, Cost Principles for Non-Profit Organizations
          A-87, Cost Principles for State, Local and Indian Tribal Governments
          A-21, Cost Principles for Educational Institutions
          48 CFR Part 31, For-Profit Organizations

                   AA Project Director:                                                                                                                 Date:
          Form Completed by:

                                 Name:

                                 Phone:
                                 Email:




DSHS Table 2                                                                                                                                                                                                 Revised 7-14-08

				
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