R93-167 AUTHORIZING AGREEMENT - CARLE CLINIC ASSOCIATION, P.C.

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, � � . � S�CTfON i - GENERAL PURPOSE • t.1 The intent of this Agresment is to estabiish a harmonious relationship between the Parties in regard to arranging fo� and paying for the provision of Demonstration Services and veatment of Patients wha elect to recaive such Demcnsvation Servic�s from Provider. SECTiON II - ELIGIBILITY REQUtREMENTS . 2.1 The Patient mc�st be entitfed to both Part A and Part B of Medicare or to Medicaid. 2.2 The Patient must have a primary diagnosis of Alzheimer`s dis2ase or related disorder made by a physician. � 2.3 The Patient must reside within tf�e Demonstration site's catc:�ment area and must not be institutionafized. 2.4 The Patient must require case management and servicss for functional disabi(ities or cognitive impairments. � 2.5 The Patient and/or their representative must agree to participate ic► tfie Demonstration and have a signed infonned consent statement on recard. 2.6 The Patient and/or their representative must agres to a 20% co-payment for Demonstration Services. 2.7 The Patient's services must be prescribed by a Demonstration case manager under an approved written pian of care. SCCTION III - COVERED ScRViCES . 3.1 Provider shall render to the Patient the Demortsuation Services that are requested by tfie cas2 manager under a written pian estabiished by the case manager and approved and signed by the Patient and/or their representative, and a healtfi professional. 3.2 Provider shail render Demonstration Services to Patients wt�a mest the eligibitity requirements defined in Section ii. 3.3 Provider shail render Demonsvation Services that me�t the captivated � funding requirement established by the Heaith Care Financing Adminisvation and approved by the case nzanager. 3.4 Provider shall render Demonsuatian Services to the Patient within 15 � days of receipt of the casa managers written request for services. , - • 2