HomeMy WebLinkAboutExhibit 3Agency for Persons with Disabilities Medicaid Waiver Services Agreement
Attachment B
DD HCBS Waiver Services Agreement
The following rate(s) has been approved for use by the Provider. In order for the provider to bill for individual services,
the Providers must be in receipt of a current Service Authorization form from an individual's Waiver Support
Coordinator. The Service authorization form will indicate the rate approved for individual services, and the frequency and
intensity of the service that has been approved.
City of Miami Parks & Recreations
Approved Rate(s) (complete as appropriate for the provider)
Billing Method
Trip
Non -Specified Rate
Mile
Month
$122.36
Table may be expanded and headings modified to better reflect approved rates and method of payment for the provider.
Page of
6
October 2003: Revised December 2004
Revised September 29, 2005
Agency for Persons with Disabilities
Transportation Data Collection Tool
APD Area Office:
Name of Provider:
Medicaid Provider Number:
ReoortinQ Period: January 1, 200 trough March 31. 200
Complete for each billing category as
appropriate to approved billing
methodology,
Wheelchair
Accessible Vehicle
Non Wheelchair Accessible
Vehicle
Total
A. Month •.
.
Total # of one-way trips
.
Total # of miles for all one-way trips
Average # of consumers sharinga
vehicle '. •
Total cost of operation during reporting
period ..
B. Trip ::;., , .
Total # of O c-way' trips
•
Total #.ofmiles for all one-way trips
Average # t -consumers sharing a .
vehicle .
•
Total cost ol'_operation during reporting
period
•
•
C. Mile
Total # of one-way trips'
Total # of m 4es for all one-way trips
'
F
Average # oLconsumers sharing a
vehicle
.
. •
Total cost of operation during reporting
period
•
GRAND TOTAL (Ali billing
Categories),
-ranriitofot way trips.' . .... •
Total # of miles for all one-way trips
,
Average of consumers sharing a
vehicle ,.
Total cost of operation during reporting
period
Signature of Provider:
Title of Provider:
Date of Signature:
Telephone #: