AGREEMENT/VARIATION REQUEST FORM - Ministry of Health

AGREEMENT/VARIATION REQUEST FORM
Does this request form replace a previous request form sent to HealthPAC Dn
Is this a: New
Do you need to terminate an existing
agreement:
agreement
(*** see note below)
If this is a variation, tick all that apply:
Term Price Volume Service Other
a) Legal Entity Name & Address:
(For new providers please attach Additions &
Amendments to the Corporate Database form
COF-10D)
b) Provider Contact Name:
Variation of
existing
agreement:
c) Trading as: (If different from above)
d) Provider Number: (From HIN)
AGREEMENT RESPONSIBILITY AND SIGN OFF
e)** Agreement Manager Name & Signature:
f) Agreement Deputy:
(Person responsible for this agreement who does not have delegated
authority-CM/Analyst)
g) Financial Analyst:
h) Directorate:
AGREEMENT DETAILS
i) Agreement Name:
(If MAPO please insert name within contract name)
j) Original Agreement No:( only required for Variations)
k) Agreement / Variation Start Date:
l) Agreement / Variation End Date:
m) Amount of this Agreement/Variation (GST
Excl) (This is the amount of the entire new agreement or variation
period only– not per annum)
n) Agreement Type: ( only required for New agreements)
o) Ethnic Classification:
(Maori, Pacific Island or General)
p) Principle DHB Name:
HealthPAC Dunedin Use Only
Agreement Generated By/Monitoring:
Quality Checked by:
Agreement File Name:
CMSDRAFT/
** Person responsible for this agreement who has delegated authority. Note this is usually an Agreement Manager.
*** If you have to terminate an existing agreement, you will need to refer to the Termination clause in that Agreement and action
accordingly, with a copy sent to HealthPAC Dunedin before this agreement can be terminated.

SERVICE DETAILS
Every service needs a separate page, or if there are several services, a spreadsheet version of the
request form is available.
The details on this page relate to: (tick which one applies)
A change to existing
The addition of a
service details
new service
If this service is replacing an
existing service please provide the
Purchase Unit ID it is replacing
ONLY fill out the payment schedule if
payment varies.
a) Facility Details Payment Schedule
Facility Name and Address
Start
Date
End
Date
Pmt
Date
Facility Number
(from PerOrg\SSSG)
Number of Contracted Beds:
Residential only
Total Number of Beds:
Service Details
b) Purchase Unit Short
Name:
c) Purchase Unit ID:
d) Ethnic Classification:
Maori, Pacific Island, General
e) GST Percentage:
f) Payment System:
Proclaim, CMS, CCPS
g) Purchase Method:
h) Price Per Unit (GST Excl):
i) Total Amount (GST Excl):
j) Total Volume
k) Payment Frequency:
l) Payment Date
(eg month of service/month
following service)
m) Agreement Service Start
Date:
n) Agreement Service End
Date:
o)Geographical Area
(for Maori Health contracts):
p) GL Code (These must be obtained from your Financial Analyst)
Co Group Resp Service Type Ministry
Pmt
Amount
GST Excl.