Common use of Reference Documents Clause in Contracts

Reference Documents. All DMC-ODS documents incorporated by reference into this Agreement may not be physically attached to the Agreement, but can be found at DHCS’ website: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreement, contract but can will be found at DHCS’ websiteissued in a CD under separate cover: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreementcontract but will be issued in a CD under separate cover: Document 1A: Title 45, but can be found at DHCS’ websiteCode of Federal Regulations 96, Subparts C and L, Substance Abuse Prevention and Treatment Block Grant Requirements Document 1B: Title 42, Code of Federal Regulations, Charitable Choice Regulations ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇▇▇▇▇.▇▇▇/cfr/text/42/part-54 Document 1C: Driving-Under-the-Influence Program Requirements Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Services Network Guidelines 2016 Document 1H(a): Service Code Descriptions Document 1J(a): Non-Drug Medi-Cal Audit Appeals Process Document 1J(b): DMC Audit Appeals Process Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (Pages/▇▇▇▇▇) .aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) Document 1T: CalOMS Prevention Data Quality Standards Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2C: Title 22, California Code of Regulations Document 2E: Drug Medi-Cal Certification Standards for Substance Abuse Clinics (Updated July 1, 2004) Document 2F: Standards for Drug Treatment Programs (October 21, 1981) Document 2G Drug Medi-Cal Billing Manual Document 2K: Multiple Billing Override Certification (MC 6700) Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMCDrug Medi-ODS Cal Cost Report Excel Workbook Forms – Intensive Outpatient Treatment – Non-Perinatal (form and instructions) Document 2P(b): Drug Medi-Cal Cost Report Forms – Intensive Outpatient Treatment – Perinatal (form and instructions) Document 2P(c): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Non-Perinatal (form and instructions) Document 2P(d): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Perinatal (form and instructions) Document 2P(e): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Non-Perinatal (form and instructions) Document 2P(f): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Perinatal (form and instructions) Document 2P(g): Drug Medi-Cal Cost Report Forms – Residential – Perinatal (form and instructions) Document 2P(h): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Non-Perinatal (form and instructions) Document 2P(i): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Perinatal (form and instructions) Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3O: Quarterly Federal Financial Management Report (QFFMR) 2014-15 ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/SUD_Forms.aspx Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreement, contract but can will be found at DHCS’ websiteissued in a CD under separate cover: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreement, contract but can will be found at DHCS’ websiteissued in a CD under separate cover: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS documents incorporated by reference into this Agreement contract may not be physically attached to the Agreementcontract, but can be found at DHCS’ website: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement Program Specifications A. This Intergovernmental Agreement (hereinafter referred to as Agreement) is entered into by and between the Department of Health Care Services (hereinafter referred to as DHCS, The Department, or the state) and the Contractor for the purpose of identifying and providing covered Drug Medi- Cal Organized Delivery System (DMC-ODS) services for substance use disorder (SUD) treatment in the Contractor’s service area pursuant to Sections 11848.5(a) and (b) of the Health and Safety Code (hereinafter referred to as HSC), Sections 14021.51–14021.53 and 14124.20– 14124.25 of the Welfare and Institutions Code (hereinafter referred to as WIC), Part 438 of the Code of Federal Regulations (hereinafter referred to as 42 CFR 438), and the Special Terms and Conditions (STCs) of the DMC-ODS waiver. B. It is further agreed this Agreement is controlled by applicable provisions of: (a) the WIC, Chapter 7, Sections 14000, et seq., in particular, but not limited to, Sections 14100.2, 14021, 14021.5, 14021.6, 14043, et seq. and

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreementcontract but will be issued in a CD under separate cover: Document 1A: Title 45, but can be found at DHCS’ websiteCode of Federal Regulations 96, Subparts C and L, Substance Abuse Prevention and Treatment Block Grant Requirements Document 1B: Title 42, Code of Federal Regulations, Charitable Choice Regulations ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇▇▇▇▇.▇▇▇/cfr/text/42/part-54 Document 1C: Driving-Under-the-Influence Program Requirements Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Services Network Guidelines 2016 Document 1H(a): Service Code Descriptions Document 1J(a): Non-Drug Medi-Cal Audit Appeals Process Document 1J(b): DMC Audit Appeals Process Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/▇▇▇▇▇.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Facility_Certification.aspx Document 1GT: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification CalOMS Prevention Data Quality Standards Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2C: Title 22, California Code of Regulations Document 2E: Drug Medi-Cal Certification Standards for Substance Abuse Clinics (Updated July 1, 2004) Document 2F: Standards for Drug Treatment Programs (October 21, 1981) Document 2G Drug Medi-Cal Billing Manual Document 2K: Multiple Billing Override Certification (MC 6700) Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMCDrug Medi-ODS Cal Cost Report Excel Workbook Forms – Intensive Outpatient Treatment – Non-Perinatal (form and instructions) Document 2P(b): Drug Medi-Cal Cost Report Forms – Intensive Outpatient Treatment – Perinatal (form and instructions) Document 2P(c): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Non-Perinatal (form and instructions) Document 2P(d): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Perinatal (form and instructions) Document 2P(e): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Non-Perinatal (form and instructions) Document 2P(f): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Perinatal (form and instructions) Document 2P(g): Drug Medi-Cal Cost Report Forms – Residential – Perinatal (form and instructions) Document 2P(h): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Non-Perinatal (form and instructions) Document 2P(i): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Perinatal (form and instructions) Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J3O: CalOMS Treatment Data Collection Guide Quarterly Federal Financial Management Report (QFFMR) 2014-15 ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/SUD_Forms.aspx Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards ▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS documents incorporated by reference into this Agreement may not be physically attached to the Agreement, but can be found at DHCS’ website: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards Document 1V: Youth Treatment Guidelines Adolescent Substance Use Disorder Best Practices Guide Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality AgreementAgreement Program Specifications

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreement, contract but can will be found at DHCS’ websiteissued in a CD under separate cover: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Documents/CalOMS_Tx_Data_Collectio n_Guide_JAN%202014.pdf Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS documents incorporated by reference into this Agreement contract may not be physically attached to the Agreementcontract, but can be found at DHCS’ website: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreementcontract but will be issued in a CD under separate cover: Document 1A: Title 45, but can be found at DHCS’ websiteCode of Federal Regulations 96, Subparts C and L, Substance Abuse Prevention and Treatment Block Grant Requirements Document 1B: Title 42, Code of Federal Regulations, Charitable Choice Regulations ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇▇▇▇▇.▇▇▇/cfr/text/42/part-54 Document 1C: Driving-Under-the-Influence Program Requirements Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Services Network Guidelines 2016 Document 1H(a): Service Code Descriptions Document 1J(a): Non-Drug Medi-Cal Audit Appeals Process Document 1J(b): DMC Audit Appeals Process Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/▇▇▇▇▇.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Facility_Certification.aspx Document 1GT: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification CalOMS Prevention Data Quality Standards Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2C: Title 22, California Code of Regulations Document 2E: Drug Medi-Cal Certification Standards for Substance Abuse Clinics (Updated July 1, 2004) ODS Waiver ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇▇ #▇▇-▇▇▇▇▇ Exhibit A ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/services/adp/Documents/DMCA_Drug_Medi- Cal_Certification_Standards.pdf Document 2F: Standards for Drug Treatment Programs (October 21, 1981) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/services/adp/Documents/DMCA_Standards_for_ Drug_Treatment_Programs.pdf Document 2G Drug Medi-Cal Billing Manual ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/formsandpubs/Documents/Info%20Notice%2020 15/DMC_Billing_Manual%20FINAL.pdf Document 2K: Multiple Billing Override Certification (MC 6700) Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMCDrug Medi-ODS Cal Cost Report Excel Workbook Forms – Intensive Outpatient Treatment – Non-Perinatal (form and instructions) Document 2P(b): Drug Medi-Cal Cost Report Forms – Intensive Outpatient Treatment – Perinatal (form and instructions) Document 2P(c): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Non-Perinatal (form and instructions) Document 2P(d): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Perinatal (form and instructions) Document 2P(e): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Non-Perinatal (form and instructions) Document 2P(f): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Perinatal (form and instructions) Document 2P(g): Drug Medi-Cal Cost Report Forms – Residential – Perinatal (form and instructions) Document 2P(h): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Non-Perinatal (form and instructions) Document 2P(i): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Perinatal (form and instructions) Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J3O: CalOMS Treatment Data Collection Guide Quarterly Federal Financial Management Report (QFFMR) 2014-15 ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/SUD_Forms.aspx Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards ▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇.▇▇▇/templates/browse.aspx?lvl=2&lvlID=15 Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreement, contract but can will be found at DHCS’ websiteissued in a CD under separate cover: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement Program Specifications A. This Intergovernmental Agreement (hereinafter referred to as Agreement) is entered into by and between the Department of Health Care Services (hereinafter referred to as DHCS, The Department, or the state) and the Contractor for the purpose of identifying and providing covered Drug Medi- Cal Organized Delivery System (DMC-ODS) services for substance use disorder (SUD) treatment in the Contractor’s service area pursuant to Sections 11848.5(a) and (b) of the Health and Safety Code (hereinafter referred to as HSC), Sections 14021.51–14021.53 and 14124.20– 14124.25 of the Welfare and Institutions Code (hereinafter referred to as W&I Code), Part 438 of the Code of Federal Regulations (hereinafter referred to as 42 CFR 438), and the Special Terms and Conditions (STCs) of the DMC-ODS waiver. B. It is further agreed this Agreement is controlled by applicable provisions of: (a) the W&I Code, Chapter 7, Sections 14000, et seq., in particular, but not limited to, Sections 14100.2, 14021, 14021.5, 14021.6, 14043, et seq. and (b) Division 4 of Title 9 of the California Code of Regulations (hereinafter referred to as Title 9). C. It is understood and agreed that nothing contained in this Agreement shall be construed to impair the single state agency authority of DHCS. D. The objective of this Agreement is to make SUD treatment services available to Medi-Cal beneficiaries through utilization of federal and state funds available pursuant to Title XIX or Title XXI of the Social Security Act (hereinafter referred to as the Act) for reimbursable covered services rendered by certified DMC providers. E. These services shall be provided though a Prepaid Inpatient Hospital Plan (PIHP) as defined in 42 CFR §438.2. F. This Agreement requires the Contractor to ensure the availability and accessibility of adequate numbers of facilities, service locations, service sites, and professional, allied and supportive personnel to provide medically necessary services, and ensure the authorization of services for urgent conditions. The DMC-ODS provides for automatic mandatory enrollment of all Medi-Cal beneficiaries in the single PIHP operating in the county in which the beneficiary resides. PIHPs in a very small county or in any one geographic area may have a limited number of providers for a particular service. If additional providers are not needed to meet general access requirements, the Contractor is not obligated to subcontract with additional providers to provide more choices for an individual beneficiary.

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreementcontract but will be issued in a CD under separate cover: Document 1A: Title 45, but can be found at DHCS’ websiteCode of Federal Regulations 96, Subparts C and L, Substance Abuse Prevention and Treatment Block Grant Requirements Document 1B: Title 42, Code of Federal Regulations, Charitable Choice Regulations ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇▇▇▇▇.▇▇▇/cfr/text/42/part-54 Document 1C: Driving-Under-the-Influence Program Requirements Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Services Network Guidelines 2016 Document 1H(a): Service Code Descriptions Document 1J(a): Non-Drug Medi-Cal Audit Appeals Process Document 1J(b): DMC Audit Appeals Process Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/▇▇▇▇▇.aspx Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Facility_Certification.aspx Document 1GT: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification CalOMS Prevention Data Quality Standards Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2C: Title 22, California Code of Regulations Document 2E: Drug Medi-Cal Certification Standards for Substance Abuse Clinics (Updated July 1, 2004) Document 2F: Standards for Drug Treatment Programs (October 21, 1981) Document 2G Drug Medi-Cal Billing Manual Document 2K: Multiple Billing Override Certification (MC 6700) Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMCDrug Medi-ODS Cal Cost Report Excel Workbook Forms – Intensive Outpatient Treatment – Non-Perinatal (form and instructions) Document 2P(b): Drug Medi-Cal Cost Report Forms – Intensive Outpatient Treatment – Perinatal (form and instructions) Document 2P(c): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Non-Perinatal (form and instructions) Document 2P(d): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Individual Counseling – Perinatal (form and instructions) Document 2P(e): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Non-Perinatal (form and instructions) Document 2P(f): Drug Medi-Cal Cost Report Forms – Outpatient Drug Free Group Counseling – Perinatal (form and instructions) Document 2P(g): Drug Medi-Cal Cost Report Forms – Residential – Perinatal (form and instructions) Document 2P(h): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Non-Perinatal (form and instructions) Document 2P(i): Drug Medi-Cal Cost Report Forms – Narcotic Treatment Program – County – Perinatal (form and instructions) Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3O: Quarterly Federal Financial Management Report (QFFMR) 2014-15 ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/SUD_Forms.aspx Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreement, contract but can will be found at DHCS’ websiteissued in a CD under separate cover: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/individuals/Documents/Youth_Treatment_Guideli nes.pdf Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/formsandpubs/Documents/DMC_Billing_Manual _2017-Final.pdf Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement

Reference Documents. All DMC-ODS The following documents are hereby incorporated by reference into this Agreement the DMC-ODS Waiver contract though they may not be physically attached to the Agreement, contract but can will be found at DHCS’ websiteissued in a CD under separate cover: ▇▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/DMC-ODS-Contracts.aspx. Document 1F(a): Reporting Requirement Matrix – County Submission Requirements for the Department of Health Care Services Document 1G: Perinatal Practice Guidelines Document 1J: Attachment Y of the DMC-ODS Special Terms and Conditions Document 1K: Drug and Alcohol Treatment Access Report (▇▇▇▇▇) Document 1P: Alcohol and/or Other Drug Program Certification Standards (March 15, 2004) ▇▇▇▇://▇▇▇.▇▇▇▇.▇▇.▇▇▇/provgovpart/Pages/Facility_Certification.aspx Document 1V: Youth Treatment Guidelines Document 2A: Sobky ▇. ▇▇▇▇▇▇, Judgment, Signed February 1, 1995 Document 2G Drug Medi-Cal Billing Manual Document 2L(a): Good Cause Certification (6065A) Document 2L(b): Good Cause Certification (6065B) Document 2P: County Certification - Cost Report Year-End Claim For Reimbursement Document 2P(a): DMC-ODS Cost Report Excel Workbook Document 3G: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 4 – Narcotic Treatment Programs Document 3H: California Code of Regulations, Title 9 – Rehabilitation and Developmental Services, Division 4 – Department of Alcohol and Drug Programs, Chapter 8 – Certification of Alcohol and Other Drug Counselors Document 3J: CalOMS Treatment Data Collection Guide Document 3S CalOMS Treatment Data Compliance Standards Document 3V Culturally and Linguistically Appropriate Services (CLAS) National Standards Document 4D : Drug Medi-Cal Certification for Federal Reimbursement (DHCS 100224A) Document 4F : Drug Medi-Cal (DMC) MC # 5312 Services Quarterly Claim for Reimbursement of County Administrative Expenses Document 5A : Confidentiality Agreement