R92-190 AUTHORIZING AGREEMENT - CARLE CLINIC ASSOCIATIONS, P.C.

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'•� Ii SECTION I - GENERAL PURPOSE ' 1 .1 The intent of this Agreement is to establish a harmonious relationship � between the Parties in regard to arranging for and paying for the provision of Demonstration '�, Services and treatment of Patients who elect to receive such Demonstration Services from I Provider. SECTION II - ELIGIBILITY REQUIREMENTS 2.1 The Patient must be entitled to both Part A and Part B of Medicare or to Medicaid. 2.2 The Patient must have a primary diagnosis of Alzheimer's disease or related disorder made by a physician. 2.3 The Patient must reside within the Demonstration site's catchment area and must not be institutionalized. 2.4 The Patient must require case management and services for functional disabilities or cognitive impairments. 2.5 The Patient and/or their representative must agree to participate in the Demonstration and have a signed informed consent statement on record. 2.6 The Patient and/or their representative must agree to a 20% c�-payment for Demonstration Services. 2.7 The Patient's services must be prescribed by a Demonstration case manager under an approved written plan of care. SECTION III - COVERED SERVICES 3.1 Provider shall render to the Patient the Demonstration Services that are requested by the case manager under a written plan established by the case manager and approved and signed by the Patient and/or their representative, and a health professional. 3.2 Provider shall render Demonstration Services to Patients who meet the eligibility requirements defined in Section II. 3.3 Provider shall render Demonstration Services that meet the captivated funding requirement established by the Health Care Financing Administration and approved by the case manager. 3.4 Provider shall render Demonstration Services to the Patient within 15 days of receipt of the case managers written request for services. 2