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FY15 INTERIM HCCBG FUNDING ALLOCATION REVISIONO C, Ic 14 Z) It 17 C� -5 zlj 10 -rJ Li Ir Ic VD t; o 55 wl pl 71O -R '2 7D Supplement to Provider Services Summary Interim HealthCare of the Eastern Carolinas, Inc. In -Home Services Detail Name of Community Service Provider DOA -732 Supplement (Effective: 7/08) July 1, 2014 through June 30, 2015 Revision # 4 A B C F G H HCCBG Required Net Projected Projected Projected In -Home Local Service HCCBG Reimbursement HCCBG In -Home Services Funding Match Cost Units Rate Clients Level I - 235 Respite 0 0 Level 1- 041 H Mgmt 22464 2496 24960 1476 16.9788 10 Subtotal Level I 22464 2496 24960 1476' z Y 10 Level II - 236 Respite 0 0 Level II - 042 PC 88484 9832 98316 5697 17.2576 32 Level II - 043 H Mgmt 0 0 Subtotal Level II 88484 9832 98316 5697 €;, 32 F Level III - 237 Respite 0 0 Level III - 044 H Mgmt 0 0 Level III - 045 PC 54416 6046 60462 3477 17.4476 15 Subtotal Level III 54416 6046 60462 3477 �� 15 Level IV - 238 Respite 0 0 Level IV - 046 H Mgmt 0 0 Subtotal Level IV 0 0 0 0€ 0 Total 165364 18374 183738 10650 t 0011 Authorize . ignature Title Date Community Service Provider 0 r rn o q �Q co C) -0 (j) Z m c 0 — m 0 0 U) 0 0 0 0 > z U) w N3 -n M < o- K-- 0 (o :I < :� A (D EL co =3 Er rr 07 C-) > cr w CD 0 m CD 0 -0 0 — 0 — 0 co < 0 (D En --1 0 — 0 — — w -0 c — -0 S. 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