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<br /> II/A
<br /> COUNTY OF TRA. VIS
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<br /> PROVIDER AGREEMENT ~o
<br /> WITH THE TEXAS DEPARTMENT OF HUMAN SERVICES
<br /> FOR PARTICIPATION IN THE TEXAS MEDICAID PROGRAM O~
<br /> ~
<br /> CITY OF SAN MARCOS ~IC PRO~RAM %.
<br /> (LegaJ: Name cí ProYider} ""<;
<br /> rÐoino &sàrwI6s kr (DBA) Name, if ~)
<br /> 630 E. HOPKTNS SAN MARCOS, TX. 78666
<br /> (Address) (City. State) ~ Code) (Medi::are PrtM:Ier N ~
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<br /> The provider agrees. in accortianœ with federal and state laws ~ regulations pertaining to the MeäJCaki program
<br /> and as a condition for participation as a provider in the Texas MeälC8J Assistance Program (MedicaJd). to the tenns
<br /> and conditions set forth below and to the Texas Medicaid Provider Procedures Maooal, a copy of which will be
<br /> furnished to the provider and which is hereby incofporated by reference as a part of this agreement '
<br /> A. To maintain and retain for a period of five (5) yèars from the date of service, or unit! audit and all audIt
<br /> exceptions are resolved. whichever period is longer, such records as are necessary to fuUy disdose the
<br /> extent of the SSMces provided to the lndivWals reœMng R$Sistanoe under the Texas MedtcakI program.
<br /> and the amount daImed for each of such services. If litigation is involved, the records rrost be retained
<br /> until litigation is ended or for five years as cited above, whichever is longer. ,
<br /> B. To provide unconditionally, upon request, free copies of and access to records pertaining to the services
<br /> for which claims are submitted to Medicaid to representatives designated by the Texas Department of
<br /> Human Services (DHS), the United States Department of Health and Human Services (HHS), the Texas
<br /> Attorney Generärs Medicaid Fraud Control Unit ancllor the health insuring contractor for Medicaid, with
<br /> respect to the operation of the Texas Medicat Assistance Program.
<br /> C. To comply with the applicable requirements of Title 42 Code of Federal Regulations, Part 455, Subpart B,
<br /> and disclose, upon request of DHS or Its health insuring contractor, information concerning ownership
<br /> and control, past and/or current business transactions, and other disdoslng entities to incJude the name
<br /> 01 any person or entity who has an ownership or control interest in or is an agent or managing ef1l)k>yee or .
<br /> entity of the organization who has been convicted of a criminal offense, patient abuse, fraud, obstruction
<br /> 01 investigation, or of offenses relating to controlled substances In any program operated by or financed in
<br /> whole or in part by any federal, state, or local government agency, or who has been formally discIplined or
<br /> sanctioned by any state heafth care licensure board, whether or not the action is related to activities in
<br /> thase programs.
<br /> D. To accept the payment establIshed by Medicaid unde¡: the State Plan as payment In fun for covered
<br /> services and to make no adãrtional charge to the patient, any merrt>er ot the family, or to any other source
<br /> for covered services, except where benefits are coordinated with Medicare or private health insurance, or
<br /> allowed in the Eyeglass or Hearing Aid Programs.
<br /> E. To comply with TItle VI of the CIvU Rights Ad of 1964 (Public Law 88-352), Section 504 of the
<br /> Rehabilitation Ad of 1973 (Public Law 93-112), The Americans with Disabifmes Ad of 1990 (Public law
<br /> 101-336), and all amendments to each, and all requirements imposed by the regulations issued pursuant
<br /> to these acts. In addition, the contractor agrees to comply with TItle 40, Chapter 73, of the Texas
<br /> Administrative Code. These provide in part that no persons In the United States shan, on the grounds of
<br /> race, roler, national origin, sex, age, disability, polItical befiefs, or religion be exduded from participation in.
<br /> or denied, any aid, care, service or other benefits provided by federal and/or state funding, or otherwise
<br /> be subjected to discrimination. To co~y with Texas Health and Safety Code Section 85.113 (relating to
<br /> workplace and confidentiality guidelines regarding AIDS and HIV).
<br /> F. To not discriminate against the individual on the basis the person is a Medicaid recipient by means of
<br /> pricing differentiais or other means of disaiminatory treatment.
<br /> G. Hospitals and home health agencies must comply with Section 4751 of the Omnibus Budget
<br /> Reconciliation Act of 1990 by:
<br /> . Providing written information 10 aft adult (as defined by state law) Individuals receiving medical care
<br /> by or through the provider or OTganization concernIng their rights under Texas law to:
<br /> - Make decisions concerning their medical care
<br /> - Accept or refuse medical or surgicaJ treatment
<br /> - FormJlate advance direct!ves (e.g., living wills or durabfe powers of anorney for health care)
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